The Better Operative Outcomes Software Tool (BOOST) Prospective Study: Improving the Quality of Cataract Surgery Outcomes in Low-Resource Settings

PURPOSE

Post-operative vision impairment is common among patients who have undergone cataract surgery in low-resource settings, impacting quality of clinical outcomes and patient experience. This prospective, multisite, single-armed, pragmatic validation study aimed to assess whether receiving tailored recommendations via the free Better Operative Outcomes Software Tool (BOOST) app improved surgical outcomes, as quantified by post-operative unaided distance visual acuity (UVA) measured 1-3 days after surgery.

METHODS

During the baseline data collection round, surgeons in low and middle-income countries recorded clinical characteristics of 60 consecutive cataract cases in BOOST. Additional data on the causes of poor outcomes from 20 consecutive cases with post-operative UVA of <6/60 (4-12 weeks post-surgery) were entered to automatically generate tailored recommendations for improvement, before 60 additional consecutive cases were recorded during the follow-up study round. Average UVA was compared between cases recorded in the baseline study round and those recorded during follow-up.

RESULTS

Among 4,233 cataract surgeries performed by 41 surgeons in 18 countries, only 2,002 (47.3%) had post-operative UVA 6/12 or better. Among the 14 surgeons (34.1%) who completed both rounds of the study (1,680 cases total), there was no clinically significant improvement in post-operative average UVA (logMAR units ±SD) between baseline (0.50 ± 0.37) and follow-up (0.47 ± 0.36) rounds (mean improvement 0.03, p = 0.486).

CONCLUSIONS

Receiving BOOST-generated recommendations did not result in improved UVA beyond what could be expected from prospective monitoring of surgical outcomes alone. Additional research is required to assess whether targeted support to implement changes could potentiate the uptake of app-generated recommendations and improve outcomes.

Tropical Data: Approach and Methodology as Applied to Trachoma Prevalence Surveys

PURPOSE

Population-based prevalence surveys are essential for decision-making on interventions to achieve trachoma elimination as a public health problem. This paper outlines the methodologies of Tropical Data, which supports work to undertake those surveys.

METHODS

Tropical Data is a consortium of partners that supports health ministries worldwide to conduct globally standardised prevalence surveys that conform to World Health Organization recommendations. Founding principles are health ministry ownership, partnership and collaboration, and quality assurance and quality control at every step of the survey process. Support covers survey planning, survey design, training, electronic data collection and fieldwork, and data management, analysis and dissemination. Methods are adapted to meet local context and needs. Customisations, operational research and integration of other diseases into routine trachoma surveys have also been supported.

RESULTS

Between 29th February 2016 and 24th April 2023, 3373 trachoma surveys across 50 countries have been supported, resulting in 10,818,502 people being examined for trachoma.

CONCLUSION

This health ministry-led, standardised approach, with support from the start to the end of the survey process, has helped all trachoma elimination stakeholders to know where interventions are needed, where interventions can be stopped, and when elimination as a public health problem has been achieved. Flexibility to meet specific country contexts, adaptation to changes in global guidance and adjustments in response to user feedback have facilitated innovation in evidence-based methodologies, and supported health ministries to strive for global disease control targets.

Integrating eye care in low-income and middle-income settings: a scoping review

OBJECTIVES

Integrated people-centred eye care has been recommended as a strategic framework for reducing global vision impairment and blindness. The extent to which eye care has integrated with other services has not been widely reported. We aimed to investigate approaches to integrating eye care service delivery with other systems in low resource settings, and identify factors associated with integration.

DESIGN

Rapid scoping review based on Cochrane Rapid Review and Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines.

DATA SOURCES

MEDLINE, Embase, Web of Science, Scopus and Cochrane Library databases were searched in September 2021.

ELIGIBILITY CRITERIA

Papers with interventions involving eye care or preventative eye care integrated into other health systems, peer-reviewed in English, conducted in low-income or middle-income countries, and published between January 2011 and September 2021 were included.

DATA EXTRACTION AND SYNTHESIS

Two independent reviewers screened, quality appraised and coded included papers. A deductive-inductive iterative analysis approach was used with a focus on integrating service delivery.

RESULTS

The search identified 3889 potential papers, of which 24 were included. Twenty papers incorporated more than one intervention type (promotion, prevention and/or treatment), but none included rehabilitation. Most articles involved human resources development yet rarely appeared to be people-centred. The level of integration was associated with building relationships and enhancing service coordination. Integrating human resources was challenged by the need for ongoing support and worker retention. In primary care settings, workers were often already at full capacity, had competing priorities, varying capabilities and limited motivation. Additional barriers included inadequate referral and information systems, poor supply chain management and procurement practices and finite financing.

CONCLUSION

Integrating eye care into low resource health systems is a challenging task, compounded by resource limitations, competing priorities and ongoing support needs. This review highlighted a need for people-centred approaches to future interventions, and further investigation into integrating vision rehabilitation services.

Toward Universal Eye Health Coverage-Key Outcomes of the World Health Organization Package of Eye Care Interventions: A Systematic Review

Importance

Despite persistent inequalities in access to eye care services globally, guidance on a set of recommended, evidence-based eye care interventions to support country health care planning has not been available. To overcome this barrier, the World Health Organization (WHO) Package of Eye Care Interventions (PECI) has been developed.

Objective

To describe the key outcomes of the PECI development.

Evidence Review

A standardized stepwise approach that included the following stages: (1) selection of priority eye conditions by an expert panel after reviewing epidemiological evidence and health facility data; (2) identification of interventions and related evidence for the selected eye conditions from a systematic review of clinical practice guidelines (CPGs); stage 2 included a systematic literature search, screening of title and abstracts (excluding articles that were not relevant CPGs), full-text review to assess disclosure of conflicts of interest and affiliations, quality appraisal, and data extraction; (3) expert review of the evidence extracted in stage 2, identification of missed interventions, and agreement on the inclusion of essential interventions suitable for implementation in low- and middle-income resource settings; and (4) peer review.

Findings

Fifteen priority eye conditions were chosen. The literature search identified 3601 articles. Of these, 469 passed title and abstract screening, 151 passed full-text screening, 98 passed quality appraisal, and 87 were selected for data extraction. Little evidence (≤1 CPG identified) was available for pterygium, keratoconus, congenital eyelid disorders, vision rehabilitation, myopic macular degeneration, ptosis, entropion, and ectropion. In stage 3, domain-specific expert groups voted to include 135 interventions (57%) of a potential 235 interventions collated from stage 2. After synthesis across all interventions and eye conditions, 64 interventions (13 health promotion and education, 6 screening and prevention, 38 treatment, and 7 rehabilitation) were included in the PECI.

Conclusions and Relevance

This systematic review of CPGs for priority eye conditions, followed by an expert consensus procedure, identified 64 essential, evidence-based, eye care interventions that are required to achieve universal eye health coverage. The review identified some important gaps, including a paucity of high-quality, English-language CPGs, for several eye diseases and a dearth of evidence-based recommendations on eye health promotion and prevention within existing CPGs.

Recruiting people with HIV to an online self-management support randomised controlled trial: barriers and facilitators

Background Recruitment of people to randomised trials of online interventions presents particular challenges and opportunities. The aim of this study was to evaluate factors associated with the recruitment of people with HIV (PWHIV) and their doctors to the HealthMap trial, a cluster randomised trial of an online self-management program.

METHODS

Recruitment involved a three-step process. Study sites were recruited, followed by doctors caring for PWHIV at study sites and finally PWHIV. Data were collected from study sites, doctors and patient participants. Factors associated with site enrolment and patient participant recruitment were investigated using regression models.

RESULTS

Thirteen study sites, 63 doctor participants and 728 patient participants were recruited to the study. Doctors having a prior relationship with the study investigators (odds ratio (OR) 13.3; 95% confidence interval (CI) 3.0, 58.7; P = 0.001) was positively associated with becoming a HealthMap site. Most patient participants successfully recruited to HealthMap (80%) had heard about the study from their HIV doctor. Patient enrolment was associated with the number of people with HIV receiving care at the site (β coefficient 0.10; 95% CI 0.04, 0.16; P = 0.004), but not with employing a clinic or research nurse to help recruit patients (β coefficient 55.9; 95% CI -2.55, 114.25; P = 0.06).

CONCLUSION

Despite substantial investment in online promotion, a previous relationship with doctors was important for doctor recruitment, and doctors themselves were the most important source of patient recruitment to the HealthMap trial. Clinic-based recruitment strategies remain a critical component of trial recruitment, despite expanding opportunities to engage with online communities.

Who benefits most from extending financial protection for cataract surgery in Vietnam? An extended cost-effectiveness analysis of small incision surgery

Treatment costs remain a barrier for having timely cataract surgery in Vietnam, particularly for females and the poor, despite significant progress in achieving universal health coverage (UHC). This study evaluated the potential impact, on health and financial protection, of eliminating medical and non-medical out-of-pocket costs associated with cataract surgery. An extended cost-effectiveness analysis (ECEA) was conducted with a societal perspective. The ECEA modelled how many more disability-adjusted life years (DALYs) and cases of catastrophic health expenditure (CHE) and medical impoverishment could be averted across income quintiles and between males and females. Two programmes were evaluated: (1) eliminating medical out-of-pocket costs for small incision cataract surgery and (2) Programme A plus a voucher programme covering non-medical out-of-pocket costs. Compared with current, the incremental cost per year of Programme A was estimated to be $833 396 and $1 641 835 for Programme B, each representing <0.01% of total health care spending in 2016. Males and females in the richest income quintiles would avert more DALYs than those in the poorest quintiles. For both programmes, most cases of CHE would be averted by individuals in the poorest income quintile. Programme B would avert the most CHE cases overall and females would have a greater share of benefits. All cases of impoverishing medical expenditure would be averted by individuals in the poorest quintile (A: 115 cases and B: 493 cases) for both programmes. The cost to avert each case of CHE with Programme A ranged from $67 to $292 and $100 to $232 for Programme B. We found a pro-rich health distribution and a pro-poor CHE distribution associated with eliminating out-of-pocket costs of cataract surgery in Vietnam. A programme that addressed both medical and non-medical out-of-pocket costs could have the greatest impact on improving financial protection in this population, particularly among the poorest income quintiles and for females. This study supports the concordance between the objectives of UHC and gender equity.

Comparison of Face Washing and Face Wiping Methods for Trachoma Control: A Pilot Study

Eye-to-eye transmission of Chlamydia trachomatis, the causative agent of trachoma, may be plausibly interrupted if faces are kept free of ocular and nasal discharge. Between April and June 2018, 83 children aged 1-9 years with active trachoma were recruited from 62 households and allocated to a face cleaning protocol: face washing with water, face washing with water and soap, or face wiping. Faces were examined for the presence of ocular and nasal discharge, and swabs were taken from faces and hands to test for C. trachomatis at baseline, immediately post protocol, and after 1, 2, and 4 hours (washing protocols). Washing with soap was more effective at removing ocular discharge than either washing with water (89% and 27% of discharge removed, respectively, P = 0.003) or wiping with a hand (42%, P = 0.013). The reduction in prevalence of ocular discharge was sustained for at least four hours. The prevalence of C. trachomatis on face swabs was reduced by all washing protocols. The importance of soap should not be overlooked during facial cleanliness promotion.

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

OBJECTIVE

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

METHOD

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

RESULT

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

CONCLUSION

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

PRACTICE IMPLICATIONS

Patient education can be delivered by group videoconferencing.

The systematic development of a complex intervention: HealthMap, an online self-management support program for people with HIV

Background

Despite persistent calls for HIV care to adopt a chronic care approach, few HIV treatment services have been able to establish service arrangements that prioritise self-management. To prevent cardiovascular and other chronic disease outcomes, the HealthMap program aims to enhance routine HIV care with opportunities for self-management support. This paper outlines the systematic process that was used to design and develop the HealthMap program, prior to its evaluation in a cluster-randomised trial.

Methods

Program development, planning and evaluation was informed by the PRECEDE-PROCOEDE Model and an Intervention Mapping approach and involved four steps: (1) a multifaceted needs assessment; (2) the identification of intervention priorities; (3) exploration and identification of the antecedents and reinforcing factors required to initiate and sustain desired change of risk behaviours; and finally (4) the development of intervention goals, strategies and methods and integrating them into a comprehensive description of the intervention components.

Results

The logic model incorporated the program’s guiding principles, program elements, hypothesised causal processes, and intended program outcomes. Grounding the development of HealthMap on a clear conceptual base, informed by the research literature and stakeholder’s perspectives, has ensured that the HealthMap program is targeted, relevant, provides transparency, and enables effective program evaluation.

Conclusions

The use of a systematic process for intervention development facilitated the development of an intervention that is patient centred, accessible, and focuses on the key determinants of health-related outcomes for people with HIV in Australia. The techniques used here may offer a useful methodology for those involved in the development and implementation of complex interventions.

Development of the Organisational Health Literacy Responsiveness (Org-HLR) self-assessment tool and process

BACKGROUND

The World Health Organization describes health literacy as a critical determinant of health and driver of citizen empowerment and health equity. Several studies have shown that health literacy is associated with a range of socioeconomic factors including educational attainment, financial position and ethnicity. The complexity of the health system influences how well a person is able to engage with information and services. Health organisations can empower the populations they serve and address inequity by ensuring they are health literacy responsive. The aim of this study was to develop the Organisational Health Literacy Responsiveness self-assessment tool (Org-HLR Tool), and an assessment process to support organisations with application of the tool.

METHODS

A co-design workshop with health and social service professionals was undertaken to inform the structure of the tool and assessment process. Participants critiqued existing self-assessment tools and discussed the likely utility of the data they generate. A review of widely used organisational performance assessment tools informed the structure and self-assessment process. The Organisational Health Literacy Responsiveness (Org-HLR) Framework (with seven domains/24 sub-domains) provided the structure for the assessment dimensions of the tool. The performance indicators were drawn from raw data collected during development of the Org-HLR Framework.

RESULTS

Twenty-two professionals participated in the workshop. Based on the feedback provided and a review of existing tools, a multi-stage, group-based assessment process for implementing the Org-HLR Tool was developed. The assessment process was divided into three parts; i) reflection; ii) self-rating; and iii) priority setting, each supported by a corresponding tool. The self-rating tool, consistent with the Org-HLR Framework, was divided into: External policy and funding environment; Leadership and culture; Systems, processes and policies; Access to services and programs; Community engagement and partnerships; Communication practices and standards; Workforce. Each of these had 1 to 5 sub-dimensions (24 in total), and 135 performance indicators.

CONCLUSIONS

The Org-HLR Tool and assessment process were developed to address a gap in available tools to support organisations to assess their health literacy responsiveness, and prioritise and plan their quality improvement activities. The tool is currently in the field for further utility and acceptability testing.

Development and testing of a framework for analysing health literacy in public policy documents

Health literacy is a driver of community empowerment and a key determinant of health and equity. The World Health Organisation has established a strong global mandate for addressing health literacy through public policy action, by positioning it as one of three key pillars for achieving sustainable development and health equity in the Shanghai Declaration on Health Promotion. Policy document analysis is a useful way of determining the strengths and limitations of past and current policies, as well as the likely success of their implementation and impact on health outcomes. In this study, we developed a framework for analysing policy documents to assess the extent to which they prioritise and operationalise an emergent public health issue, in this case health literacy. Specifically, the framework enables a systematic exploration of (i) the stated policy goals and strategic objectives; (ii) the stated policy actions; and (iii) whether there is an intention to resource and monitor the stated policy activities. We tested the utility of the framework by applying it to a set of public policies in the Australian context. The framework presented in this study may be a useful tool for systematically analysing policy documents to reveal their strengths and limitations, and the extent to which they prioritise and operationalise health literacy.

Measuring cancer caregiver health literacy: Validation of the Health Literacy of Caregivers Scale-Cancer (HLCS-C) in an Australian population

Caregivers have been largely neglected in health literacy measurement. We assess the construct validity, and internal consistency of the Health Literacy of Caregivers Scale-Cancer (HLCS-C), and present a revised, psychometrically robust scale. Using data from 297 cancer caregivers (12.4% response rate) recruited from Melbourne, Australia between January-July 2014, confirmatory factor analysis (CFA) was conducted to evaluate the HLCS-C's proposed factor structure. Items were evaluated for: item difficulty, unidimensionality and overall item fit within their domain. Item-threshold-ordering was examined though one-parameter Item Response Theory models. Internal consistency was assessed using Raykov's reliability coefficient. CFA results identified 42 poorly performing/redundant items which were subsequently removed. A 10-factor model was fitted to 46 acceptable items with no correlated residuals or factor cross-loadings accepted. Adequate fit was revealed (χ²_WLSMV  = 1463.807[df = 944], p < .001, RMSEA = 0.043, CFI = 0.980, TLI = 0.978, WRMR = 1.00). Ten domains were identified: Proactivity and determination to seek information; Adequate information about cancer and cancer management; Supported by healthcare providers (HCP) to understand information; Social support; Cancer-related communication with the care recipient (CR); Understanding CR needs and preferences; Self-care; Understanding the healthcare system; Capacity to process health information; and Active engagement with HCP. Internal consistency was adequate across domains (0.78-0.92). The revised HLCS-C demonstrated good structural, convergent, and discriminant validity, and high internal consistency. The scale may be useful for the development and evaluation of caregiver interventions.

Conceptualisation and development of the Conversational Health Literacy Assessment Tool (CHAT)

Background

The aim of this study was to develop a tool to support health workers’ ability to identify patients’ multidimensional health literacy strengths and challenges. The tool was intended to be suitable for administration in healthcare settings where health workers must identify health literacy priorities as the basis for person-centred care.

Methods

Development was based on a qualitative co-design process that used the Health Literacy Questionnaire (HLQ) as a framework to generate questions. Health workers were recruited to participate in an online consultation, a workshop, and two rounds of pilot testing.

Results

Participating health workers identified and refined ten questions that target five areas of assessment: supportive professional relationships, supportive personal relationships, health information access and comprehension, current health behaviours, and health promotion barriers and support.

Conclusions

Preliminary evidence suggests that application of the Conversational Health Literacy Assessment Tool (CHAT) can support health workers to better understand the health literacy challenges and supportive resources of their patients. As an integrated clinical process, the CHAT can supplement existing intake and assessment procedures across healthcare settings to give insight into patients’ circumstances so that decisions about care can be tailored to be more appropriate and effective.

Development of the organisational health literacy responsiveness (Org-HLR) framework in collaboration with health and social services professionals

BACKGROUND

The health literacy skills required by individuals to interact effectively with health services depends on the complexity of those services, and the demands they place on people. Public health and social service organisations have a responsibility to provide services and information in ways that promote equitable access and engagement, that are responsive to diverse needs and preferences, and support people to participate in decisions regarding their health and wellbeing. The aim of this study was to develop a conceptual framework describing the characteristics of health literacy responsive organisations.

METHODS

Concept mapping (CM) workshops with six groups of professionals (total N = 42) from across health and social services sectors were undertaken. An online concept mapping consultation with 153 professionals was also conducted. In these CM activities, participants responded to the seeding statement "Thinking broadly from your experiences of working in the health system, what does an organisation need to have or do in order to enable communities and community members to fully engage with information and services to promote and maintain health and wellbeing". The CM data were analysed using multidimensional scaling and hierarchical cluster analyses to derive concept maps and cluster tree diagrams. Clusters from the CM processes were then integrated by identifying themes and subthemes across tree diagrams.

RESULTS

Across the workshops, 373 statements were generated in response to the seeding statement. An additional 1206 statements were generated in the online consultation. 84 clusters were derived within the workshops and 20 from the online consultation. Seven domains of health literacy responsiveness were identified; i) External policy and funding environment; ii) Leadership and culture; iii) Systems, processes and policies; iv) Access to services and programs; v) Community engagement and partnerships; vi) Communication practices and standards; and vii) Workforce. Each domain included 1 to 5 sub-domains (24 sub-domains in total).

CONCLUSIONS

Using participatory research processes, a conceptual framework describing the characteristics, values, practices and capabilities of organisational health literacy responsiveness was derived. The framework may guide the planning and monitoring of health service and health system improvements, and has the potential to guide effective public health policy and health system reforms.

Systematic development and implementation of interventions to OPtimise Health Literacy and Access (Ophelia)

BACKGROUND

The need for healthcare strengthening to enhance equity is critical, requiring systematic approaches that focus on those experiencing lesser access and outcomes. This project developed and tested the Ophelia (OPtimising HEalth LIteracy and Access) approach for co-design of interventions to improve health literacy and equity of access. Eight principles guided this development: Outcomes focused; Equity driven, Needs diagnosis, Co-design, Driven by local wisdom, Sustainable, Responsive and Systematically applied. We report the application of the Ophelia process where proof-of-concept was defined as successful application of the principles.

METHODS

Nine sites were briefed on the aims of the project around health literacy, co-design and quality improvement. The sites were rural/metropolitan, small/large hospitals, community health centres or municipalities. Each site identified their own priorities for improvement; collected health literacy data using the Health Literacy Questionnaire (HLQ) within the identified priority groups; engaged staff in co-design workshops to generate ideas for improvement; developed program-logic models; and implemented their projects using Plan-Do-Study-Act (PDSA) cycles. Evaluation included assessment of impacts on organisations, practitioners and service users, and whether the principles were applied.

RESULTS

Sites undertook co-design workshops involving discussion of service user needs informed by HLQ (n = 813) and interview data. Sites generated between 21 and 78 intervention ideas and then planned their selected interventions through program-logic models. Sites successfully implemented interventions and refined them progressively with PDSA cycles. Interventions generally involved one of four pathways: development of clinician skills and resources for health literacy, engagement of community volunteers to disseminate health promotion messages, direct impact on consumers' health literacy, and redesign of existing services. Evidence of application of the principles was found in all sites.

CONCLUSIONS

The Ophelia approach guided identification of health literacy issues at each participating site and the development and implementation of locally appropriate solutions. The eight principles provided a framework that allowed flexible application of the Ophelia approach and generation of a diverse set of interventions. Changes were observed at organisational, staff, and community member levels. The Ophelia approach can be used to generate health service improvements that enhance health outcomes and address inequity of access to healthcare.

Global Health Systems and Policy Development: Implications for Health Literacy Research, Theory and Practice

Accessible and responsive health systems are critical to population health and human development. While progress has been made toward global health and development targets, significant inequities remain within and between countries. Expanding health inequities suggest a widespread and systemic neglect of vulnerable citizens, and a failure to enshrine within policies a responsibility to tailor care to the variable capabilities of citizens. Implementation of health and social policies that drive the design of accessible health systems, services, products and infrastructure represents the next frontier for health reform. Within this chapter we argue the need to consider health and health literacy across policy domains, to operationalize the intent to address inequities in health in meaningful and pragmatic ways, and to actively monitor progress and impact within the context of the Sustainable Development Goals (SDGs). We contend that viewing and developing policies and systems within a health literacy framework will assist in placing citizens and equity considerations at the center of development efforts. In this chapter, we explore the relationship between health literacy and equitable access to health care, and the role of health system and policy reform. We first explore international policies, health literacy, and the SDGs. We then explore national policies and the role that national and local services and systems play in building health literacy, and responding to the health literacy challenges of citizens. We discuss the World Health Organization's (WHO) Framework for Integrated People-Centered Health Services and the way in which health services are being encouraged to understand and respond to citizen health literacy needs. Each section of the chapter ends with a summary and a review of health literacy research and practice. Throughout, we illustrate our points through 'vignettes' from around the world.

Health Literacy in Selected Populations: Individuals, Families, and Communities from the International and Cultural Perspective

International and cultural perspectives of health literacy help deepen the understanding of the global context within which health literacy plays an important role. Throughout this chapter, we explore the significance of health literacy initiatives, interventions, practices, and research for addressing health challenges on a variety of levels in the international and global context. More specifically, in this chapter, the notion of health literacy as a dynamic construct is introduced, after which we examine health literacy throughout the life course, emphasizing the impact of health literacy among children and the elderly in their families and in the community. Cultural norms and family interpersonal relations, and values influence health literacy and need to be considered when closing the health literacy disparities. Global trends of migration and immigration bring to the forefront the need for unravelling the complexity of health systems, for which health literacy plays a central role; health literacy initiatives address cultural differences between providers and patients to help narrow the communication gap. The importance of cultural competency among health care providers exemplifies how capacity building in health literacy is critical for maximizing the benefits to the public of the health care system. Health literacy provides a conceptual foundation for community participatory research, involving members of the public to take part in the planning, execution and evaluation of health education interventions. Throughout the chapter, selected case studies and picture boxes from around the globe, exemplify aforementioned topics of interest, showcased in the chapter. Practical recommendations for policy makers, practitioners and research are offered based on the studies conducted in the international context.

Multifaceted Assessment of Health Literacy in People Receiving Dialysis: Associations With Psychological Stress and Quality of Life

Health literacy (HL) refers to a person's ability to engage effectively with health information and services. We aimed to describe the HL of people receiving dialysis and the factors associated with it. A cross-sectional design was used, with demographic and clinical data as predictors. Participants were people receiving dialysis at a metropolitan health service in Melbourne, Australia. Health consumers with conditions not requiring dialysis were included for comparison. The Health Literacy Questionnaire, Kidney Disease Quality of Life-36, and Depression Anxiety Stress Scales-21 were administered. Participants (M age = 68.2 ± 13.7 years; n = 57 males) were 76 people receiving hemodialysis within a dialysis unit, 16 people receiving home peritoneal dialysis, and 8 people receiving home hemodialysis. Participants scored higher on the HL domains social support for health and engagement with health care providers but lower on active management of health than the comparison group (n = 813). Hierarchical cluster analysis revealed 2 clusters within the dialysis sample representing higher (n = 43) and lower (n = 57) profiles of HL. The higher HL cluster reported better quality of life across 4 of 5 domains of the Kidney Disease Quality of Life-36, fewer symptoms of depression and anxiety, and higher serum albumin (mean difference = 2.06 g/L, p = .04) than the lower HL cluster. These results show that people receiving dialysis feel better supported and informed about their health than other health consumers but are less active in managing it. Higher HL is associated with better mental health and quality of life. Identifying HL characteristics may help direct specific interventions to improve patient education and support.

A systematic analysis of the needs of people with HIV in Australia: stakeholder views of the key elements for a healthy life

Background: The HealthMap project is developing an intervention to reduce cardiovascular risk in people living with HIV. As part of the formative stages of the intervention design, we sought to understand the needs of people with HIV (PWHIV). Methods: Two concept-mapping workshops with PWHIV (n=10), and one with HIV care providers (n=6) were conducted. The workshop findings were consolidated into a questionnaire administered to PWHIV (n=300) and HIV care providers (n=107). Participants were asked to rate the importance of each of 81 presented needs and the degree to which it was currently being met. Results: Workshops provided insights into what PWHIV perceive they need, to live with and manage their condition, and its impact on their life; these included: (1) clinical science research and development; (2) information and support; (3) personal situation; (4) healthcare quality; (5) access to services; (6) access to services specific to ageing; and (7) social justice. Questionnaire results revealed that PWHIV considered information and support, and research and development most important. For providers, healthcare quality, clients' personal situation, and social justice were most important. In terms of unmet needs, PWHIV and providers both highlighted issues in the areas of social justice, and access to aged care services. Conclusions: PWHIV and HIV providers continue to report unmet needs in the areas of social justice and emerging concerns about access to aged care services. Services must continue to address these issues of access and equity.

HealthMap: a cluster randomised trial of interactive health plans and self-management support to prevent coronary heart disease in people with HIV

BACKGROUND

The leading causes of morbidity and mortality for people in high-income countries living with HIV are now non-AIDS malignancies, cardiovascular disease and other non-communicable diseases associated with ageing. This protocol describes the trial of HealthMap, a model of care for people with HIV (PWHIV) that includes use of an interactive shared health record and self-management support. The aims of the HealthMap trial are to evaluate engagement of PWHIV and healthcare providers with the model, and its effectiveness for reducing coronary heart disease risk, enhancing self-management, and improving mental health and quality of life of PWHIV.

METHODS/DESIGN

The study is a two-arm cluster randomised trial involving HIV clinical sites in several states in Australia. Doctors will be randomised to the HealthMap model (immediate arm) or to proceed with usual care (deferred arm). People with HIV whose doctors are randomised to the immediate arm receive 1) new opportunities to discuss their health status and goals with their HIV doctor using a HealthMap shared health record; 2) access to their own health record from home; 3) access to health coaching delivered by telephone and online; and 4) access to a peer moderated online group chat programme. Data will be collected from participating PWHIV (n = 710) at baseline, 6 months, and 12 months and from participating doctors (n = 60) at baseline and 12 months. The control arm will be offered the HealthMap intervention at the end of the trial. The primary study outcomes, measured at 12 months, are 1) 10-year risk of non-fatal acute myocardial infarction or coronary heart disease death as estimated by a Framingham Heart Study risk equation; and 2) Positive and Active Engagement in Life Scale from the Health Education Impact Questionnaire (heiQ).

DISCUSSION

The study will determine the viability and utility of a novel technology-supported model of care for maintaining the health and wellbeing of people with HIV. If shown to be effective, the HealthMap model may provide a generalisable, scalable and sustainable system for supporting the care needs of people with HIV, addressing issues of equity of access.

TRIAL REGISTRATION

Universal Trial Number (UTN) U111111506489; ClinicalTrial.gov Id NCT02178930 submitted 29 June 2014.

Distribution of health literacy strengths and weaknesses across socio-demographic groups: a cross-sectional survey using the Health Literacy Questionnaire (HLQ)

Background

Recent advances in the measurement of health literacy allow description of a broad range of personal and social dimensions of the concept. Identifying differences in patterns of health literacy between population sub-groups will increase understanding of how health literacy contributes to health inequities and inform intervention development. The aim of this study was to use a multi-dimensional measurement tool to describe the health literacy of adults in urban and rural Victoria, Australia.

Methods

Data were collected from clients (n = 813) of 8 health and community care organisations, using the Health Literacy Questionnaire (HLQ). Demographic and health service data were also collected. Data were analysed using descriptive statistics. Effect sizes (ES) for standardised differences in means were used to describe the magnitude of difference between demographic sub-groups.

Results

Mean age of respondents was 72.1 (range 19–99) years. Females comprised 63 % of the sample, 48 % had not completed secondary education, and 96 % reported at least one existing health condition. Small to large ES were seen for mean differences in HLQ scales between most demographic groups. Compared with participants who spoke English at home, those not speaking English at home had much lower scores for most HLQ scales including the scales ‘Understanding health information well enough to know what to do’ (ES −1.09 [95 % confidence interval (CI) -1.33 to −0.84]), ‘Ability to actively engage with healthcare providers’ (ES −1.00 [95 % CI −1.24, −0.75]), and ‘Navigating the healthcare system’ (ES −0.72 [95 % CI −0.97, −0.48]). Similar patterns and ES were seen for participants born overseas compared with those born in Australia. Smaller ES were seen for sex, age group, private health insurance status, number of chronic conditions, and living alone.

Conclusions

This study has revealed some large health literacy differences across nine domains of health literacy in adults using health services in Victoria. These findings provide insights into the relationship between health literacy and socioeconomic position in vulnerable groups and, given the focus of the HLQ, provide guidance for the development of equitable interventions.

Development of a conceptual model of cancer caregiver health literacy

Caregivers play a vital role in caring for people diagnosed with cancer. However, little is understood about caregivers' capacity to find, understand, appraise and use information to improve health outcomes. The study aimed to develop a conceptual model that describes the elements of cancer caregiver health literacy. Six concept mapping workshops were conducted with 13 caregivers, 13 people with cancer and 11 healthcare providers/policymakers. An iterative, mixed methods approach was used to analyse and synthesise workshop data and to generate the conceptual model. Six major themes and 17 subthemes were identified from 279 statements generated by participants during concept mapping workshops. Major themes included: access to information, understanding of information, relationship with healthcare providers, relationship with the care recipient, managing challenges of caregiving and support systems. The study extends conceptualisations of health literacy by identifying factors specific to caregiving within the cancer context. The findings demonstrate that caregiver health literacy is multidimensional, includes a broad range of individual and interpersonal elements, and is influenced by broader healthcare system and community factors. These results provide guidance for the development of: caregiver health literacy measurement tools; strategies for improving health service delivery, and; interventions to improve caregiver health literacy.

Development of the Health Literacy of Caregivers Scale - Cancer (HLCS-C): item generation and content validity testing

BACKGROUND

Health literacy refers to an individual's ability to engage with health information and services. Cancer caregivers play a vital role in the care of people with cancer, and their capacity to find, understand, appraise and use health information and services influences how effectively they are able to undertake this role. The aim of this study was to develop an instrument to measure health literacy of cancer caregivers.

METHOD

Content areas for the new instrument were identified from a conceptual model of cancer caregiver health literacy. Item content was guided by statements provided by key stakeholders during consultation activities and selected to be representative across the range of cancer caregiver experiences. Content validity of items was assessed through expert review (n = 7) and cognitive interviews with caregivers (n = 16).

RESULTS

An initial pool of 82 items was generated across 10 domains. Two categories of response options were developed for these items: agreement with statements, and difficulty undertaking presented tasks. Expert review revealed that the majority of items were relevant and clear (Content Validity Index > 0.78). Cognitive interviews with caregivers suggested that all except three items were well understood.

CONCLUSION

A resultant 88 item questionnaire was developed to assess cancer caregiver health literacy. Further work is required to assess the construct validity and reliability of the new measure, and to remove poorly performing and redundant items, which will result in a shorter, final measure. The new measure has the potential to inform the development and evaluation of interventions and the improvement of health service delivery to cancer caregivers.

The OPtimising HEalth LIterAcy (Ophelia) process: study protocol for using health literacy profiling and community engagement to create and implement health reform

BACKGROUND

Health literacy is a multi-dimensional concept comprising a range of cognitive, affective, social, and personal skills and attributes. This paper describes the research and development protocol for a large communities-based collaborative project in Victoria, Australia that aims to identify and respond to health literacy issues for people with chronic conditions. The project, called Ophelia (OPtimising HEalth LIterAcy) Victoria, is a partnership between two universities, eight service organisations and the Victorian Government. Based on the identified issues, it will develop and pilot health literacy interventions across eight disparate health services to inform the creation of a health literacy response framework to improve health outcomes and reduce health inequalities.

METHODS/DESIGN

The protocol draws on many inputs including the experience of the partners in previous co-creation and roll-out of large-scale health-promotion initiatives. Three key conceptual models/discourses inform the protocol: intervention mapping; quality improvement collaboratives, and realist synthesis. The protocol is outcomes-oriented and focuses on two key questions: 'What are the health literacy strengths and weaknesses of clients of participating sites?', and 'How do sites interpret and respond to these in order to achieve positive health and equity outcomes for their clients?'. The process has six steps in three main phases. The first phase is a needs assessment that uses the Health Literacy Questionnaire (HLQ), a multi-dimensional measure of health literacy, to identify common health literacy needs among clients. The second phase involves front-line staff and management within each service organisation in co-creating intervention plans to strategically respond to the identified local needs. The third phase will trial the interventions within each site to determine if the site can improve identified limitations to service access and/or health outcomes.

DISCUSSION

There have been few attempts to assist agencies to identify, and respond, in a planned way, to the varied health literacy needs of their clients. This project will assess the potential for targeted, locally-developed health literacy interventions to improve access, equity and outcomes.

Unemployment, contraceptive behaviour and reproductive outcomes among young Australian women

AIMS

To examine whether unemployment and partnership affects pregnancy, live births and terminations among young Australian women. Unemployment has conventionally been used in epidemiological studies to examine the health effects of loss of opportunity, material resources and satisfaction associated with work. During welfare reform in the 1990s it was argued that unemployment and associated welfare receipt could influence reproductive choice.

DESIGN

As part of the Australian Longitudinal Study of Women's Health, information on employment, contraceptive use and pregnancy, live births and terminations was obtained at two time points. Information on partnership, age, parental education, and area economic resources was also obtained. The sample included 9683 women aged 18-23 years in 1996 (time 1) and 2000 (time 2).

ANALYSIS

Logistic regressions were conducted to assess the relationship between unemployment and contraceptive use at time 1 and the impact of unemployment at time 1 on pregnancy, live births and terminations at time 2. Analyses accounted for partnership, significant differences in contraception, age, parental education and area economic resources.

RESULTS

Despite the absence of differences in overall rates of contraceptive use, rates of pregnancy and live births among young unemployed women were higher than rates among employed women. These differences became non-significant when differences in the need to use contraception and oral contraceptive use were taken into account. There were no differences in terminations due to unemployment overall but partnered unemployed women were more likely to have a termination than other women.

CONCLUSIONS

The study did not support the notion that being unemployed provided incentives for single motherhood. However excess terminations suggest that unemployment might provide disincentives to continuing pregnancies among partnered and unemployed women. More detailed examination of contraception and partnership may be key in unraveling inconsistencies in past research.

A review of the psychometric properties of the Health of the Nation Outcome Scales (HoNOS) family of measures

Background

The Health of the Nation Outcome Scales was developed to routinely measure outcomes for adults with mental illness. Comparable instruments were also developed for children and adolescents (the Health of the Nation Outcome Scales for Children and Adolescents) and older people (the Health of the Nation Outcome Scales 65+). All three are being widely used as outcome measures in the United Kingdom, Australia and New Zealand. There is, however, no comprehensive review of these instruments. This paper fills this gap by reviewing the psychometric properties of each.

Method

Articles and reports relating to the instruments were retrieved, and their findings synthesised to assess the instruments' validity (content, construct, concurrent, predictive), reliability (test-retest, inter-rater), sensitivity to change, and feasibility/utility.

Results

Mostly, the instruments perform adequately or better on most dimensions, although some of their psychometric properties warrant closer examination.

Conclusion

Collectively, the Health of the Nation Outcome Scales family of measures can assess outcomes for different groups on a range of mental health-related constructs, and can be regarded as appropriate for routinely monitoring outcomes.

Assessing the capacity of the health services research community in Australia and New Zealand

BACKGROUND: In order to profile the health services research community in Australia and New Zealand and describe its capacity, a web-based survey was administered to members of the Health Services Research Association of Australia and New Zealand (HSRAANZ) and delegates of the HSRAANZ's Third Health Services Research and Policy Conference. RESULTS: Responses were received from 191 individuals (68%). The responses of the 165 (86%) who conducted or managed health services research indicated that the health services research community in Australia and New Zealand is characterised by highly qualified professionals who have come to health services research via a range of academic and professional routes (including clinical backgrounds), the majority of whom are women aged between 35 and 54 who have mid- to senior- level appointments. They are primarily employed in universities and, to a lesser extent, government departments and health services. Although most are employed in full time positions, many are only able to devote part of their time to health services research, often juggling this with other professional roles. They rely heavily on external funding, as only half have core funding from their employing institution and around one third have employment contracts of one year or less. Many view issues around building the capacity of the health services research community and addressing funding deficits as crucial if health services research is to be translated into policy and practice. Despite the difficulties they face, most are positive about the support and advice available from peers in their work settings, and many are actively contributing to knowledge through academic and other written outputs. CONCLUSION: If health services research is to achieve its potential in Australia and New Zealand, policy-makers and funders must take the concerns of the health services research community seriously, foster its development, and contribute to maximising its capacity through a sustainable approach to funding. There is a clear need for a strategic approach, where the health services research community collaborates with competitive granting bodies and government departments to define and fund a research agenda that balances priority-driven and investigator-driven research and which provides support for training and career development.

Estimated noise distributions across stages of consciousness utilizing the Fsp quantification technique

We used the Fsp technique to quantify the influence of changing stages of consciousness on the signal-to-noise ratio of the middle latency response (MLR). The MLR and polysomnographic activity were obtained from 10 subjects during a continuous 6-hour period. The Fsp statistic was applied to the MLR data in order to determine the number of scores above a specified criterion in each stage of consciousness and time window of analysis. Results demonstrated that the number of Fsp scores exceeding the criterion of acceptance decreased with increasing depth of sleep. The awake stage yielded the greatest proportion of scores above the criterion. The background noise data were analyzed separately. The distributions of noise differed as a function of stage of consciousness.

A comparison of endovascular assisted and conventional in situ bypass grafts

Thirty-three in situ saphenous vein bypass grafts were performed using a conventional open technique (CI) while 31 in situ bypass grafts were performed using endovascular occlusion of side branches (EAI). Bypass grafts were performed from the femoral to the popliteal (n = 37) or a trifurcation (n = 27) artery for claudication (n = 7), rest pain (n = 14), or tissue loss (n = 43). Wound complications developed in 11 Cl and four EAI limbs. Postoperative hospitalization in CI and EAI patients was, respectively, 8.4 +/- 2.0 days and 4 +/- 1.6 days. Missed arteriovenous fistulas were noted in one CI and 17 EAI limbs postoperatively. At follow-up four (12%) CI and six (19%) EAI grafts were occluded or had undergone revision surgery. Based on life-table analysis CI and EAI cumulative patency rates at 18 months were 79% and 83%, respectively. Although this new technique (EAI bypass grafting) did not reduce operative time, it did decrease the length of surgical incisions and the duration of postoperative hospitalization (p < 0.001, Student's t test). Wound complications occurred less frequently in EAI limbs but the incidence of missed arteriovenous fistulas was significantly higher. These data suggest that EAI and CI patency is comparable. Ultimately long-term patency will be the crucial test for determining the utility of this new technique.

Esophageal obstruction in a tracheostomized infant

Partial esophageal obstruction was an unusual complication of tracheostomy in an infant. Emesis and failure to thrive prompted a modified barium-swallow study, which revealed that the tracheostomy tube was causing an obstruction in the proximal esophagus. Use of a shorter, customized tube eliminated the esophageal obstruction, allowing normal feeding and weight gain.

Evidence that the onset of the breeding season in the ewe may be independent of decreasing plasma prolactin concentrations

Ten ewes of each of two breeds, Dorset Horn (long breeding season) and Welsh Mountain (short breeding season), were given subcutaneous oestradiol-17 beta implants and then ovariectomized. Another 10 ewes of each breed were left intact. On 3 May 1982, all the ewes were housed in an artificial photoperiod of 16L:8D. After 4 weeks, half of the ewes of each breed and physiological state were abruptly exposed to a short-day (8L:16D) photoperiod while the others remained in long days (16L:8D). The time of onset of the breeding season was significantly (P less than 0.05) advanced in ewes switched to short days (12 August +/- 10 days) compared to those maintained in long days (4 September +/- 14 days). Dorset Horn ewes began to cycle (20 July +/- 7 days) significantly (P less than 0.001) earlier than Welsh Mountain ewes (19 September +/- 6 days). Disparities in the time of onset of cyclic activity in ewes of different breeds and daylength groups were echoed in disparities in the time at which plasma LH and FSH concentrations rose in oestrogen-implanted, ovariectomized ewes of the same light treatment group. Prolactin concentrations showed an immediate decrease in ewes switched to short days, but remained elevated in long-day ewes. Since the breeding season started in the presence of high prolactin concentrations in long-day ewes, it seems unlikely that prolactin is an important factor determining the timing of the onset of cyclic activity.