Effect of cognitive dysfunction on the relationship between age and health literacy

Objective

Age is generally an inverse predictor of health literacy. However, the role of cognitive dysfunction among older adults in this relationship is not understood.

Methods

We conducted a cross-sectional survey of 446 adult patients in a large urban academic level one trauma center, assessing health literacy and cognitive dysfunction.

Results

Removing older patients (60 years of age and older) who screened positive for cognitive dysfunction attenuated the relationship between age and health literacy (r = −0.16, p = 0.001 vs. r = −0.35, p < 0.0001). Older patients screening positive for cognitive dysfunction had significantly lower health literacy than older patients screening negative and patients less than 60 years; health literacy scores did not generally differ significantly between the latter groups.

Conclusion

Much of the relationship between age and health literacy was driven by cognitive dysfunction among a subset of older adults.

Practice implications

Our findings suggest that older patients with cognitive dysfunction have the greatest need for health literacy interventions.     

Which women patients have better health literacy in Serbia?

Objective

To evaluate health literacy among female primary care patients and the possible factors which contribute to better health literacy.

Methods

A cross-sectional study was conducted among 824 female primary health care patients. Functional health literacy was measured by the Serbian version of the Short Test of Functional Health Literacy in Adults (STOFHLA). Chi-square testing and logistic regression analyses were applied.

Results

We found that inadequate or marginal health literacy was present in 363 participants (44.1%) and adequate health literacy was present in 461 participants (55.9%). Functional health literacy was significantly different by age, marital status, employment, education, material status, self-perception of health, and health status. Based on multivariate analysis, health literacy was significantly associated with participant age, employment status, level of education, and perception of health.

Conclusion

Better health literacy existed among younger, employed participants with a higher education and better self-perception of health.

Practice implications

Strengthening the knowledge and evidence base for measuring and assessing health literacy are action points for health strategies to decrease the ill effects of low health literacy.     

Abilities,skills and knowledge in measures of health literacy

Objective

Health literacy has been recognized as an important factor in patients’ health status and outcomes, but the relative contribution of demographic variables, cognitive abilities, academic skills, and health knowledge to performance on tests of health literacy has not been as extensively explored. The purpose of this paper is to propose a model of health literacy as a composite of cognitive abilities, academic skills, and health knowledge (ASK model) and test its relation to measures of health literacy in a model that first takes demographic variables into account.

Methods

A battery of cognitive, academic achievement, health knowledge and health literacy measures was administered to 359 Spanish- and English-speaking community-dwelling volunteers. The relations of health literacy tests to the model were evaluated using regression models.

Results

Each health literacy test was related to elements of the model but variability existed across measures.

Conclusion

Analyses partially support the ASK model defining health literacy as a composite of abilities, skills, and knowledge, although the relations of commonly used health literacy measures to each element of the model varied widely.

Practice implications

Results suggest that clinicians and researchers should be aware of the abilities and skills assessed by health literacy measures when choosing a measure.     

Health literacy and its association with perception of teratogenic risks and health behavior during pregnancy

Objective

Investigate the association between health literacy and perception of medication risk, beliefs about medications, use and non-adherence to prescribed pharmacotherapy during pregnancy, and whether risk perception and beliefs may mediate an association between health literacy and non-adherence.

Methods

This multinational, cross-sectional, internet-based study recruited pregnant woman between 1 October 2011 and 29 February 2012. Data on maternal socio-demographics, medication use, risk perception, beliefs, and non-adherence were collected via an on-line questionnaire. Health literacy was measured via a self-assessment scale. Mann–Whitney U test, Spearman's rank correlation, Generalized Estimating Equations and mediation analysis were utilized.

Results

4999 pregnant women were included. Low-health literacy women reported higher risk perception for medications, especially penicillins (Rho: −0.216) and swine flu vaccine (Rho: −0.204) and more negative beliefs about medication. Non-adherence ranged from 19.2% (high-health literacy) to 25.0% (low-health literacy). Low-health literacy women were more likely to be non-adherent to pharmacotherapy than their high-level counterparts (adjusted OR: 1.30; 95% CI: 1.02–1.66). Risk perception and beliefs appeared to mediate the association between health literacy and non-adherence.

Conclusion

Health literacy was significantly associated with maternal health behaviors regarding medication non-adherence.

Practice implications

Clinicians should take time to inquire into their patients’ ability to understand health information, perception and beliefs, in order to promote adherence during pregnancy.     

Effects of mild and global cognitive impairment on the prevalence of fear of falling in community-dwelling older adults

Objectives

Few studies have reported the relationship between fear of falling (FoF) and mild and global cognitive impairment in community-dwelling older adults. We aimed to determine whether the status of cognitive impairment affects the prevalence of FoF in community-dwelling older adults.

Study design

Cross-sectional study among 4474 community-dwelling older adults who participated in the Obu Study of Health Promotion for the Elderly.

Main outcome measures

Participants underwent cognitive tests and were divided into three groups: cognitive healthy, mild cognitive impairment (MCI), and global cognitive impairment (GCI). FoF and related variables, such as fall history, physical function, and depression, were also investigated.

Results

The prevalence of FoF was significantly different by group (p < 0.001; healthy: 43.6%, MCI: 50.6%, GCI: 40.6%). Logistic regression analysis showed that GCI (odds ratio = 0.63; 95% confidence interval = 0.526–0.76) was independently associated with FoF, after controlling for confounding factors. Older adults with GCI showed the lowest prevalence of FoF, although they had the lowest physical function comparing with the other groups (p < 0.001).

Conclusion

MCI and GCI in community-dwelling older adults affect the prevalence of FoF in a completely different manner. Further study is required to determine whether insensitivity to FoF with GCI increases the risk of falling in older adults.     

Education,literacy, and health: Mediating effects on hypertension knowledge and control

Objective

To determine whether literacy mediates the association between education, hypertension knowledge and control.

Methods

In-person interviews with a literacy assessment and chart review were conducted with 330 hypertensive patients from six primary care safety net clinics. Mediational analysis was used to test the role of literacy skills in explaining the relationship between education and hypertension knowledge and control.

Results

In multivariate analyses that did not make an adjustment for the other variable, both lower educational attainment and more limited literacy were found to be significant independent predictors of poorer hypertension knowledge and control. When literacy was entered into models that included education only, the association between education and knowledge was fully attenuated and no longer significant (Grades 1–8: β = −0.30, 95% CI = −1.44–0.83), while the relationship between education and blood pressure control was only minimally reduced (AOR 2.46, 95% CI 2.10–2.88). More limited literacy skills also was associated with hypertension control in the final model (AOR 2.68, 95% CI 1.54–4.70).

Conclusion

Patient literacy mediated the relationship between education and hypertension knowledge. Literacy was a significant independent predictor of blood pressure control, but only minimally explained the relationship between education and blood pressure.

Practice implications

Health literacy is critical to the design of educational tools to improve knowledge acquisition. However, in order to impact health outcome, future health literacy studies should also address other psychosocial factors that impact motivation and capability to manage disease.     

Functional health literacy in Switzerland—Validation of a German,Italian, and French health literacy test

Objective

This study aimed to translate and validate German, Italian, and French versions of the Short-Test of Functional Health Literacy (S-TOFHLA), to be used in Switzerland and its neighboring countries.

Methods

The original English version of the S-TOFHLA was translated by applying standardized translation methods and cultural adaptations. 659 interviews were conducted with Swiss residents in their preferred language (249 German, 273 Italian, and 137 French). To assess the validity of the measures, known predictors for health literacy (age, education, and presence of a chronic condition) were tested.

Results

For all three language versions, results show that younger participants, participants with a higher education and participants with chronic medical conditions had significantly higher levels of health literacy. Furthermore, the three health literacy scales categorized participants into three health literacy levels with most people possessing either inadequate or adequate levels. The highest levels of health literacy were found in the Swiss-German sample (93%), followed by the Swiss-French (83%) and Swiss-Italian (67%) samples.

Conclusion

The German, Italian, and French versions of the S-TOFHLA provide valid measures of functional health literacy.

Practice implications

The translated versions can be used in the three different language regions of Switzerland as well as in neighboring countries following ‘country specific’ adjustments and validations.     

How to ask: Older adults’ preferred tools in health outcome prioritization

Objective

To assess older adults’ attitudes toward eliciting health outcome priorities.

Methods

This observational cohort study of 356 community-living adults age ≥65 included three tools: (1) Health Outcomes: ranking four outcomes (survival, function, freedom from pain, and freedom from other symptoms); (2) Now vs. Later: rating importance of current versus future quality of life; (3) Attitude Scale: agreement with statements about health outcomes and current versus future health.

Results

Whereas 41% preferred Health Outcomes, 40% preferred the Attitude Scale. Only 7–12% rated any tool as very hard or hard. In bivariate analysis, participants of non-white race and with lower education, health literacy, and functional status were significantly more likely to rate at least one of the tools as easy (p < .05). Across all tools, 17% of participants believed tools would change care. The main reason for thinking there would be no change was satisfaction with existing care (62%).

Conclusions

There is variability in how older persons wish to be asked about health outcome priorities. Few find this task difficult, and difficulty was not greater among participants with lower health literacy, education, or health status.

Practice implications

By offering different tools, healthcare providers can help patients clarify their health outcome priorities.     

Cognitive functions and cognitive styles in young euthymic patients with bipolar I disorder

Background

Recent evidences suggest that bipolar disorder patients do not return to premorbid functioning levels during the inter-episode periods. Cognitive deficits may impair patients working and functioning status and may also have negative impact on other aspects of thinking.

Objectives

To assess the prevalence of cognitive dysfunction in patients with bipolar disorder in euthymic state and to explore any evident cognitive style problems.

Method

Case-control naturalistic study 60 patients with bipolar I disorder in euthymic state according to DSM-IV were recruited and subdivided into two groups each contains of 30 patients; (Group BPM) euthymic patients with recent manic episode, and Group BPD euthymic patients with recent depressive episode. Both groups were further compared with control group (Group C) consisted of 30 frequency matched healthy volunteers. Groups were subjected to the following: 1-clinical psychiatric examination, 2-Hamilton Depression Scale (HAMD-17) and Bech–Rafaelsen Melancholia Scale (MES) for patients’ group (BPD), 3-Young Mania Rating Scale (YMRS) and Bech–Rafaelsen Mania Scale (MAS) for patients’ group (BPM), 4-assessment of euthymic state of mood included both MAS and MES, 5-MMSE, MTS and CDT were performed to assess cognitive functions, 6-cognitive styles evaluation included Fear of Failure, Hopelessness Scale, (the Social Dysfunction and Aggression Scale SDAS-9 and Arabic Anger Scale.

Results

Definite cognitive function impairment and different patterns of cognitive style were detected in case groups. MMSE, MTS and CDT scores were statistically significant. Fear of Failure Scale Scores were higher in BPM; 16 (53.33%) reported severe intensity compared to 16 (53.33%) of BPD Group reporting moderate intensity and 30 (100%) of the control group reporting only mild intensity of fear of failure with statistically significant differences. Although patients were in euthymic state; Hopelessness Scale discriminated between those with affective disorders and controls and other scores for hostility SADS-9 and Arabic Anger Scale. Moreover, measures of cognitive styles showed differences among patients of the case groups who joined psychotherapy program in their management (28) compared to those who did not (32).

Limitation

Cognitive impact of psychotropic drugs could not be eliminated since the current study is naturalistic study.

Conclusions

Those with BAD in euthymic state suffer from cognitive dysfunction and some aspects of cognitive styles that may negatively interfere with their performance. Psychotherapeutic programs should consider these findings in their approaches for better impact on patients’ quality of life and overall treatment outcome.     

The relationship between health literacy and knowledge improvement after a multimedia type 2 diabetes education program

Objective

Multimedia diabetes education programs (MDEP) have the potential to improve communication and education of those with low health literacy. We examined the effect of a MDEP targeted to patients with low literacy on knowledge and assessed the association between literacy and knowledge improvement.

Methods

We showed the MDEP to 190 patients recruited from clinics at a federally qualified health center and an academic health center. We measured diabetes knowledge before and after viewing the MDEP.

Results

Seventy-nine percent of patients had adequate literacy, 13% marginal, and 8% inadequate literacy. Patients across all literacy levels had significant increases in knowledge scores after viewing the MDEP (p-value < 0.001). Patients with inadequate literacy learned significantly less after the MDEP (adjusted beta-coefficient = −2.3, SE = 0.70) compared to those with adequate literacy.

Conclusions

A MDEP designed for those with low literacy significantly increased diabetes knowledge across literacy levels. However, the MDEP did not overcome the learning gap between patients with low and high literacy.

Practice implications

A literacy appropriate MDEP may be an effective way to teach patients about diabetes. Combining the MDEP with other education methods may improve comprehension and learning among those with low literacy. Research is needed to identify which characteristics of low-literate patients influence the ability to learn health information. Identifying these factors and incorporating solutions into a diabetes education intervention may help bridge the learning gap related to literacy status.     

Time to sign: The relationship between health literacy and signature time

Objective

To evaluate the relationship between amount of time taken to sign one's name and health literacy.

Methods

A prospective, one time assessment was conducted on a convenience sample of 98 patients recruited in an inner-city outpatient internal medicine clinic. The amount of time required to sign (i.e. initiation to completion of writing) was measured by stopwatch. Health literacy was measured with the REALM.

Results

The sample averaged 54.1 (SD 16.2) years of age. Twenty-seven percent had less than high school education and 33% had a terminal general equivalency diploma or high school degree. The time required to sign ranged from 0.91 to 21.3 s. Sixty-two percent of the sample had health literacy challenges. Signature time was longest for those with inadequate health literacy (mean 10.0 s), compared with marginal (7.3 s) and adequate (4.7 s, p ≤ 0.001). Signature time remained significant in a logistic regression model after controlling for education and age (AOR = 0.785, CI = 0.661–0.932).

Conclusion

Individuals with signatures completed in six seconds or less were highly likely to display adequate health literacy.

Practice implications

Signature time may offer a practical and quick approach to health literacy screening in the health care setting.     

Distinct alterations in value-based decision-making and cognitive control in suicide attempters: Toward a dual neurocognitive model

Objective

The literature suggests that many suicide attempters show impairment in both decision-making and cognitive control. However, it is not clear if these deficits are linked to each other, and if they may be related to more basic alterations in attention. This is a relevant question in the perspective of future interventions targeting cognitive deficits to prevent suicidal acts.

Method

Two different populations of patients with histories of suicide attempts were assessed (N=142 and 119). The Iowa Gambling Task (IGT) was used to measure decision-making in both populations. We used a D2 cancellation task and a verbal working memory task in population 1; the Stroop test, the N-Back task, the Trail Making Test, and the Hayling Sentence Completion test in population 2.

Results

Regarding decision-making, we only found a small negative correlation between the Hayling test error score (r=−0.24; p=0.01), and the net score from the second half of the IGT. In contrast, working memory, cognitive flexibility and cognitive inhibition measures were largely inter-correlated.

Limitation

Most patients were medicated. Only patients with mood disorders.

Conclusion

These results add to previous findings suggesting that the neurocognitive vulnerability to suicidal behavior may rely on impairments in two distinct anatomical systems, one processing value-based decision-making (associated with ventral prefrontal cortex, among others) and one underlying cognitive control (associated with more dorsal prefrontal regions). This distinction may result in tailored-made cognitive interventions.     

Caregiver health literacy and adherence to a daily multi-vitamin with iron regimen in infants

Objective

To determine whether or not limited caregiver health literacy is associated with adherence to a daily multi-vitamin with iron regimen in infants.

Methods

110 caregiver/infant dyads were enrolled in a prospective study to assess the relationship between caregiver health literacy and adherence to a daily multi-vitamin with iron regimen for infants. Households were contacted biweekly over a 3-month period. Adherence was based upon caregiver report. High adherence, our primary outcome, was defined as the administration of the multi-vitamin with iron on 5–7 days over the past week.

Results

As measured by the Short Test of Functional Health Literacy in Adults (S-TOFHLA), 18% of caregivers had limited health literacy skills. Caregivers with limited health literacy skills were more likely to have higher adherence than caregivers with adequate health literacy, after adjusting for a number of possible confounding variables (AOR = 2.13; 95% 1.20–3.78).

Conclusion

Caregivers with limited health literacy were twice as likely to report high adherence to a daily multi-vitamin with iron regimen in infants as caregivers with adequate health literacy in adjusted analysis.

Practice implications

Health literacy may exert a differential influence on adherence depending upon the complexity of the desired health behavior.     

Using computer agents to explain medical documents to patients with low health literacy

Objective

Patients are commonly presented with complex documents that they have difficulty understanding. The objective of this study was to design and evaluate an animated computer agent to explain research consent forms to potential research participants.

Methods

Subjects were invited to participate in a simulated consent process for a study involving a genetic repository. Explanation of the research consent form by the computer agent was compared to explanation by a human and a self-study condition in a randomized trial. Responses were compared according to level of health literacy.

Results

Participants were most satisfied with the consent process and most likely to sign the consent form when it was explained by the computer agent, regardless of health literacy level. Participants with adequate health literacy demonstrated the highest level of comprehension with the computer agent-based explanation compared to the other two conditions. However, participants with limited health literacy showed poor comprehension levels in all three conditions. Participants with limited health literacy reported several reasons, such as lack of time constraints, ability to re-ask questions, and lack of bias, for preferring the computer agent-based explanation over a human-based one.

Conclusion

Animated computer agents can perform as well as or better than humans in the administration of informed consent.

Practice implications

Animated computer agents represent a viable method for explaining health documents to patients.     

Health literacy awareness training for healthcare workers: improving knowledge and intentions to use clear communication techniques

Objective

Health literacy is a growing concern as its relationship with health outcomes becomes clearer. Efforts to enhance awareness of patient health literacy in health professional education have focused on physicians, and the objective of this research was to provide an initial assessment of a training session designed for healthcare workers of all kinds.

Methods

Pre- and post-surveys were completed by 166 participants (N = 166) in training sessions designed to improve knowledge of health literacy and instruction in clear communication techniques. Participants provided baseline and post-training assessments of perceived knowledge of health literacy and use of strategies to improve communication with low health literate audiences.

Results

Participants, initially overestimating their own knowledge of health literacy, improved on outcome measures regarding perceived health literacy knowledge. Participants also indicated strong intentions to use clear communication techniques covered in the training.

Conclusion

Results suggest there is an opportunity and need to improve health literacy training for healthcare workers of all kinds. Widespread adoption of health literacy training programs would improve the delivery of healthcare to low health literate patients.

Practice implications

Participants initially overestimated their knowledge of health literacy, suggesting a need to improve initial training and continuing medical education regarding health literacy.     

Acceptability of health information technology aimed at environmental health education in a prenatal clinic

Objective

To describe the acceptability of an interactive computer kiosk that provides environmental health education to low-income Latina prenatal patients.

Methods

A mixed-methods approach was used to assess the acceptability of the Prenatal Environmental Health Kiosk pregnant Latina women in Salinas, CA (n = 152). The kiosk is a low literacy, interactive touch-screen computer program with an audio component and includes graphics and an interactive game.

Results

The majority had never used a kiosk before. Over 90% of women reported that they learned something new while using the kiosk. Prior to using the kiosk, 22% of women reported their preference of receiving health education from a kiosk over a pamphlet or video compared with 57% after using the kiosk (p < 0.01). Qualitative data revealed: (1) benefit of exposure to computer use; (2) reinforcing strategy of health education; and (3) popularity of the interactive game.

Conclusion

The Prenatal Environmental Health Kiosk is an innovative patient health education modality that was shown to be acceptable among a population of low-income Latino pregnant women in a prenatal care clinic.

Practice implications

This pilot study demonstrated that a health education kiosk was an acceptable strategy for providing Latina prenatal patients with information on pertinent environmental exposures.     

Testing whether decision aids introduce cognitive biases: Results of a randomized trial

Objective

Women at high risk of breast cancer face a difficult decision whether to take medications like tamoxifen to prevent a first breast cancer diagnosis. Decision aids (DAs) offer a promising method of helping them make this decision. But concern lingers that DAs might introduce cognitive biases.

Methods

We recruited 663 women at high risk of breast cancer and presented them with a DA designed to experimentally test potential methods of identifying and reducing cognitive biases that could influence this decision, by varying specific aspects of the DA across participants in a factorial design.

Results

Participants were susceptible to a cognitive bias – an order effect – such that those who learned first about the risks of tamoxifen thought more favorably of the drug than women who learned first about the benefits. This order effect was eliminated among women who received additional information about competing health risks.

Conclusion

We discovered that the order of risk/benefit information influenced women's perceptions of tamoxifen. This bias was eliminated by providing contextual information about competing health risks.

Practice implications

We have demonstrated the feasibility of using factorial experimental designs to test whether DAs introduce cognitive biases, and whether specific elements of DAs can reduce such biases.     

The relationship between caregiver functional oral health literacy and child oral health status

Objective

To describe the relationship between caregivers’ oral health literacy (OHL) and the oral health status of their children in an Asian population.

Methods

A random sample of 301 child/caregiver dyads was recruited from kindergartens in Hong Kong. Two locally-developed and validated OHL assessment tasks were administered to caregivers with Hong Kong Rapid Estimate of Adult Literacy in Dentistry-30 (HKREALD-30) assessing word recognition and Hong Kong Oral Health Literacy Assessment Task for Paediatric Dentistry (HKOHLAT-P) assessing comprehension. Their children's oral health status was assessed [dental caries experience – decayed, missing, filled teeth index – (dmft) and oral hygiene status – Visible Plaque Index (VPI)].

Results

Caregivers’ literacy was associated with children's oral health status. The HKOHLAT-P had a stronger association with children's oral health than HKREALD-30. HKOHLAT-P and HKREALD-30 remained associated with dmft in the adjusted negative binomial regression models (accounting for socio-demographics), Incidence Rate Ratio (IRR) 0.97, p = 0.02, and 0.96, p = 0.03, respectively. In the adjusted model, HKOHLAT-P was associated with VPI (IRR 0.90, p < 0.05), but no association between HKREALD-30 and VPI was evident.

Conclusion

The main conclusion of this study was that caregiver oral health literacy was associated with their child's oral health status. A comprehension instrument had a more robust association with children's oral status than a word recognition instrument.

Practice implications

This study has implications for general public health education for designing community-level interventions.     

Health literacy and self-efficacy for participating in colorectal cancer screening: The role of information processing

Objective

This study aimed to document the association between health literacy and willingness and ability to seek information about the new colorectal cancer (CRC) screening program in the UK.¹ We also assessed self-efficacy for screening to determine the impact of health literacy on perceived confidence to take part in screening.

Methods

Ninety-six participants aged 50–69 years completed the British version of the Test of Functional Health Literacy in Adults (TOFHLA) (UK-TOFHLA) and used an interactive information menu to select information on why and how to participate in CRC screening. We derived a measure of reading effort by calculating the average amount of time spent reading individual information links. Each participant also completed a measure of comprehension, and self-efficacy for participating in screening.

Results

A multivariate analysis supported the hypothesis that lower health literacy would be associated with less information-seeking (b = .079, 95% confidence interval, .001–.157) greater effort in reading (b = −.965, 95% CI, −1.457 to −.473) and less self-efficacy for CRC screening (b = .61, 95% CI, .009–.131).

Conclusion

Lower health literacy had a direct impact on information-seeking. It was also independently associated with perceived confidence to participate in screening.

Practice implications

Reliance on printed communication when inviting low literate adults for screening can be problematic. The independent association between health literacy and self-efficacy further adds to the challenge of developing accessible and effective health promotion materials in this area.     

Health literacy,alcohol expectancies,and alcohol use behaviors in teens

Objective

Alcohol expectancies are developed, in part, through exposure to health messages, the understanding of which may be influenced by health literacy. This study explores the relationships among health literacy, alcohol expectancies, and alcohol use behaviors in teens.

Methods

We studied alcohol use behaviors in the past six months in youths aged 14–19 recruited from two adolescent medicine clinics. We assessed covariate-adjusted bivariate relationships between HL, expectancies, and four measures of alcohol use and tested health literacy as a moderator of the relationship between expectancies and use.

Results

Of the 293 study teens, 45 percent reported use of alcohol in the past six months. Use behaviors were positively associated with higher health literacy and positive expectancies. Our moderation model suggested that health literacy moderates the relationship between expectancies and use, with the expectancy/use relationship being significantly stronger in higher literacy teens.

Conclusion

Findings suggest that health literacy can influence alcohol expectancies and behaviors.

Practice implications

Health literacy should be explicitly considered in the design of alcohol prevention messages.