Correlating reading comprehension and health numeracy among adults with low literacy

Objective

Using the Test of Functional Health Literacy for Adults (TOFHLA), a pilot study was conducted to assess whether reading comprehension and numeracy scores sufficiently correlate in health contexts among adults with low literacy skills.

Methods

The TOFHLA was administered to 144 adults with low literacy enrolled in a health literacy program prior to the start of coursework. Raw scores for reading and numeracy were calculated. Weighted numeracy scores were calculated and compared to raw reading comprehension scores.

Results

Among 143 participants, 20% (n = 28) had a higher numeracy score than reading comprehension score, while an additional 20% scored lower in numeracy than in reading comprehension.

Conclusion

This study found that reading comprehension and numeracy skill in the context of understanding health information do not necessarily correlate for specific disadvantaged groups. This finding calls attention to the need to further examine numeracy as a construct which is conceptually separate from reading comprehension, and highlights the importance of including a numerate component in health literacy evaluations.

Practice implications

The results of this study have important implications for medical decision-makers, health educators, and health promoters working with traditional methods of assessing health literacy.     

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.     

Association of age, health literacy, and medication management strategies with cardiovascular medication adherence

Objective

To examine patients’ use of medication management strategies (e.g., reminders, pill boxes), and to determine how their use influences the relationship between patient characteristics and medication adherence.

Methods

Retrospective and cross-sectional study of 434 patients with coronary heart disease, examining both refill adherence and self-reported adherence.

Results

The most common strategy for managing refills was seeing a near empty pill bottle (89.9%), and for managing daily medications, it was associating medications with daily events (80.4%). Age < 65 (OR = 1.7), as well as marginal (OR = 2.0) or inadequate health literacy (OR = 1.9), was independently associated with low refill adherence. Patients <65 also had lower self-reported adherence (OR = 1.8). Adjustment for use of medication management strategies did not substantially change these relationships. Reliance on reminders from friends or family to take medications, or waiting to refill a medicine only when the bottle was near empty, each were associated with 3-fold greater odds of non-adherence.

Conclusion

Age <65 and marginal or inadequate health literacy were independently associated with medication non-adherence. Use of medication management strategies did not explain these relationships.

Practice implications

The strategies which patients report using to assist with managing medication refills and daily medication use may be ineffective.     

Single-item or two-item literacy screener to predict the S-TOFHLA among adult hemodialysis patients

Objective

We compared single-item (SILS) and two-item (TILS) literacy screeners in predicting Short Test of Functional Health Literacy in Adults (S-TOFHLA) scores.

Methods

Adult hemodialysis patients completed SILS, which determines need for assistance when reading written medical information; TILS (last grade completed and self-reported reading ability); and S-TOFHLA. Receiver operator characteristic curves (ROC) and stratum specific likelihoods were calculated.

Results

Of 227 participants, median S-TOFHLA was 24 (IQR 15–34). 129 (55%) participants had adequate, 70 (30%) inadequate, and 37 (16%) marginal health literacy. SILS and TILS predicted S-TOFHLA scores equivalently. Test characteristics predicting inadequate health literacy were: SILS sensitivity for threshold >1, 54% (95%CI: 44, 64), for >2, 39% (29, 49) and specificity for >1, 73% (64, 80), for >2, 93% (87, 97), area under the ROC of 0.67 (0.60–0.74); TILS sensitivity for threshold >1, 72% (62, 80), for >2, 30% (21, 40) and specificity for >1, 54% (45, 63), for >2, 86% (79, 92), area under the ROC of 0.66 (0.59–0.73).

Conclusion

SILS and TILS had similar test characteristics in predicting S-TOFHLA.

Practice implications

While a positive result on either test increases the likelihood that a patient has low health literacy, the SILS is easier to administer and score.     

Health literacy and cancer screening: A systematic review

Objective

To evaluate published evidence about health literacy and cancer screening.

Methods

Seven databases were searched for English language articles measuring health literacy and cancer screening published in 1990–2011. Articles meeting inclusion criteria were independently reviewed by two investigators using a standardized data abstraction form. Abstracts (n = 932) were reviewed and full text retrieved for 83 articles. Ten articles with 14 comparisons of health literacy and cancer screening according to recommended medical guidelines were included in the analysis.

Results

Most articles measured health literacy using the S-TOFHLA instrument and documented cancer screening by self-report. There is a trend for an association of inadequate health literacy and lower cancer screening rates, however, the evidence is mixed and limited by study design and measurement issues.

Conclusion

A patient's health literacy may be a contributing factor to being within recommended cancer screening guidelines.

Practice implications

Future research should: be conducted using validated health literacy instruments; describe the population included in the study; document cancer screening test completion according to recommended guidelines; verify the completion of cancer screening tests by medical record review; adjust for confounding factors; and report effect size of the association of health literacy and cancer screening.     

Author Index

Objective

To operationally define cancer literacy, understanding which aspects of cancer are important to be known by a layperson to be considered cancer literate.

Methods

A Delphi study in three consecutive rounds was conducted among a panel of Swiss cancer experts (oncologists, GPs, nurses from oncology wards, social workers, public health experts).

Results

The result of the Delphi process is a first operational definition of the concept of cancer literacy, a list of the aspects of cancer that, in the expert's view, laypeople should know to be considered cancer literate.

Conclusions

We have now an idea of what should be known about cancer. The study also provides us with some useful hints about what should be communicated about cancer, e.g. via public communication campaigns, school education, or media.

Practice implications

The operational definition of the concept can be used for the development and the validation of a measure of cancer literacy, not anymore limited to basic literacy and numeracy skills.     

Education level, not health literacy, associated with information needs for patients with cancer

Objective

Cancer patients receiving adjuvant therapy encounter increasingly complex situations and decisions with each new procedure and therapy. To make informed decisions about care, they need to be able to access, process, and understand information. Individuals with limited health literacy may not be able to obtain or understand important information about their cancer and treatment. The rate of low health literacy has been shown to be higher among African Americans than among non-Hispanic Whites. This study examined the associations between race, health literacy, and self-reported needs for information about disease, diagnostic tests, treatments, physical care, and psychosocial resources.

Methods

Measures assessing information needs were administered to 138 newly diagnosed cancer patients. Demographics were assessed by survey and health literacy was assessed with two commonly used measures: the Rapid Estimate Adult Literacy in Medicine (REALM) and the Short Test of Health Literacy in Adults (STOFHLA).

Results

Study findings indicate that educational attainment, rather than health literacy, is a significant predictor of information needs.

Conclusion

Overcoming barriers to information needs may be less dependent on literacy considerations and more dependent on issues that divide across levels of educational attainment.

Practice implications

Oncologists and hospital staff should be attentive to the fact that many patients require additional assistance to meet their information needs.     

Validity of a low literacy version of the Decisional Conflict Scale

Objective

To evaluate the psychometric properties of the 4-factor low literacy Decisional Conflict Scale (DCS-LL) with men eligible for prostate cancer screening (PCS).

Methods

We used baseline (T0; n = 149) and post-intervention (T2; n = 89) data from a randomized, controlled trial of a PCS decision aid to assess internal consistency reliability and construct, discriminant, and factor validity.

Results

There was evidence of excellent internal consistency reliability (α’s ≥ .80) and fair construct validity (most r's ≥ .40) for the DCS-LL except for the Supported subscale. The DCS-LL was able to discriminate between men who had decided and those who had not. There was evidence for the original 4-factor model at T0 but exploratory analysis suggested a 3-factor solution at T0 and T2 with Informed and Value Clarity as one factor.

Conclusion

For men eligible for PCS, feeling informed and feeling clear about values may not reflect distinct cognitive processes. Feeling supported may not be a factor contributing to uncertainty.

Practice Implications

Research should address whether current DCS subscales best represent the factors that contribute to uncertainty for PCS and for other screening decisions. Research should also explore the influence of health literacy on the factor structure of the DCS-LL.     

International application of health literacy measures: Adaptation and validation of the newest vital sign in The Netherlands

Objective

The newest vital sign assesses individual reading and numeracy skills. The aim of this study was to create a Dutch version (NVS-D) and to assess its feasibility, reliability, and validity in The Netherlands.

Methods

We performed a qualitative study among experts (n = 27) and patients (n = 30) to develop the NVS-D and to assess its feasibility. For validation, we conducted a quantitative survey (n = 329). Reliability was assessed by Cronbach's alpha. Construct validity was examined by analyzing association patterns. Receiver operating characteristic (ROC) curves determined optimal cut-off scores.

Results

Cronbach's alpha was 0.76. In accordance with a priori hypotheses we found strong associations between NVS-D, general vocabulary, prose literacy and objective health literacy, and weaker associations between NVS-D and subjective health literacy. A score of ≥4 out of 6 best distinguished individuals with adequate versus inadequate health literacy.

Conclusion

The results suggest that the NVS-D is a reliable and valid tool that allows international comparable health literacy research in The Netherlands.

Practice implications

The NVS-D can be applied in research on the role of health literacy in health and health care, and the development of interventions. The methods can be applied in cross-cultural adaptation of health literacy measures in other countries.     

The relationship of patient participation and diabetes outcomes for patients with high vs. low health literacy

Objective

To examine whether patient participation in medical consultations have differing effects on self-efficacy and diabetes control by the level of patient communicative health literacy (CHL).

Methods

Participants were 143 outpatients with type 2 diabetes at a university-affiliated hospital. Patient CHL was measured using a newly developed self-rated scale of health literacy. Patient perceived participation in medical consultations and self-efficacy of diabetes self-care were assessed using the self-reported questionnaire. Patient clinical characteristics were obtained from electronic medical records.

Results

Both patient CHL and perceived participation were related to greater self-efficacy and decreased HbA1c at the 3-month follow-up. Patient CHL had a moderating effect on the relationship between perceived participation and self-efficacy. Patients with lower CHL reported greater self-efficacy when they actively participated in patient-physician communication, whereas this relationship was less evident among patients with higher CHL.

Conclusions

The examination of patient CHL levels may provide a better understanding of the potential barriers to patients’ self-management of disease.

Practice implications

The benefit of active participation may be greater among patients with lower CHL who are likely to have greater difficulties in communicating with the physician, yet tend to rely on the physician as the sole source of health information.     

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.     

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.     

The effect of school-based cervical cancer education on perceptions towards human papillomavirus vaccination among Hong Kong Chinese adolescent girls

Objective

To evaluate the effects of school-based cervical cancer education on Hong Kong Chinese adolescent girls.

Methods

Adolescent girls (n = 953) in local secondary schools attended a tailored educational program on cervical cancer prevention. Self-administered questionnaires were used before and after the program to measure its effects on participants’ knowledge, attitude and perceived social norms towards human papillomavirus (HPV) vaccination and their intention to be HPV vaccinated.

Results

Before the program, HPV vaccine acceptance was favorable but relevant knowledge was low. After the program, participants had greater knowledge and a more positive attitude (both p < 0.001), with more girls anticipating family (41.6% before vs. 58.9% after) and peer support (32.8% before vs. 56.9% after). There were 11.3% more girls who indicated an intention to accept the vaccine afterward. More knowledge, a more positive attitude and perceived support from significant others predicted a stronger intention to be HPV vaccinated.

Conclusion

The educational program had a positive impact on participants’ perceptions towards HPV vaccination and their intention to be vaccinated.

Practice implications

School-based cervical cancer education is a viable means to meet the substantial educational needs of adolescents. Promotion of HPV vaccination should also include educating and influencing perceptions of families and peers.     

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.     

Improving diet and exercise in pregnancy with Video Doctor counseling: a randomized trial

Objective

To determine if an interactive, computerized Video Doctor counseling tool improves self-reported diet and exercise in pregnant women.

Methods

A randomized trial comparing a Video Doctor intervention to usual care in ethnically diverse, low-income, English-speaking pregnant women was conducted. Brief messages about diet, exercise, and weight gain were delivered by an actor-portrayed Video Doctor twice during pregnancy.

Results

In the Video Doctor group (n = 158), there were statistically significant increases from baseline in exercise (+28 min), intake of fruits and vegetables, whole grains, fish, avocado and nuts, and significant decreases in intake of sugary foods, refined grains, high fat meats, fried foods, solid fats, and fast food. In contrast, there were no changes from baseline for any of these outcomes in the usual care group (n = 163). Nutrition knowledge improved significantly over time in both groups but more so in the Video Doctor group. Clinician-patient discussions about these topics occurred significantly more frequently in the Video Doctor group. There was no difference in weight gain between groups.

Conclusion

A brief Video Doctor intervention can improve exercise and dietary behaviors in pregnant women.

Practice implications

The Video Doctor can be integrated into prenatal care to assist clinicians with effective diet and exercise counseling.     

Measuring oral contraceptive knowledge: a review of research findings and limitations

Objective

Poor oral contraceptive (OC) knowledge may contribute to premature OC discontinuation and unintended pregnancy. Yet, to understand relationships between OC knowledge and contraceptive behavior, knowledge must be adequately measured. This review evaluates the findings and methodological limitations of research in which OC knowledge has been measured.

Methods

We performed a systematic review of primary research from January 1965 to January 2009. Studies were audited for study characteristics, purpose for measuring OC knowledge, key findings and measurement properties including administration method, knowledge domains, reliability, validity, health literacy and cultural sensitivity.

Results

We reviewed 21 studies: 18 cohort studies, including one psychometric evaluation, and three randomized trials. Results on OC knowledge outcomes were variable. Measures were largely self-administered survey (n = 15) and lacked assessment of all OC knowledge domains. Information on measures’ characteristics, reliability, validity, health literacy and cultural sensitivity was limited.

Conclusion

Existing OC knowledge measures lack critical psychometric elements, leading to inconsistent and unreliable findings.

Practice implications

Poor OC knowledge measurement precludes identifying counseling needs and developing interventions for contraceptive behavior change. Future research considerations include: measurement information in publications, psychometric evaluations, formal reliability/validity techniques, and attention to all OC knowledge domains, health literacy and cultural sensitivity.     

Addressing health literacy through clear health communication: A training program for internal medicine residents

Objective

To develop, pilot, and test the effectiveness of a clear health communication curriculum to improve resident knowledge, attitudes, and skills regarding health literacy.

Methods

Thirty-one internal medicine residents participated in a small group curriculum that included didactic teaching, practice with a standardized patient, and individualized feedback on videotaped encounters with real patients. Outcomes were assessed using a pre-post survey and a communication skills checklist.

Results

Mean knowledge scores increased significantly from 60.3% to 77.6% (p < 0.001). Residents also reported increased familiarity with the concept of health literacy (mean response 3.2 vs. 4.5 on a 5 point scale), importance placed on health literacy (4.2 vs. 4.9), frequency of considering health literacy in patient care (3.3 vs. 4.0), and confidence in communicating with low literacy patients (3.3 vs. 4.1) (all p < 0.001). Use of plain language increased significantly from 33% to 86% (p = 0.023). There were nonsignificant increases in the use of teach-back (0–36%, p = 0.116) and encouraging questions (0–14%, p = 0.502).

Conclusion

Training in clear health communication improves resident knowledge, attitudes, and skills regarding health literacy.

Practice implications

The increased use of clear health communication techniques can significantly improve the care and outcomes of vulnerable patients with limited health literacy.     

The role of numeracy on client knowledge in BRCA genetic counseling

Objective

To assess the impact of numeracy and health literacy on client's ability to learn information orally communicated during a BRCA 1/2 genetic counseling session.

Methods

Fifty-nine videotaped simulated genetic counseling sessions were shown to 246 analogue clients (AC) recruited to imagine themselves as the client in the genetic counseling session. AC numeracy, genetic literacy, state and trait anxiety, and decisional conflict were assessed. The primary outcome was AC learning about BRCA 1/2.

Results

Health literacy and numeracy were moderately correlated, and each independently predicted learning. Higher numeracy was associated with higher knowledge scores only among ACs with adequate literacy. Decisional conflict was not related to literacy, numeracy, or knowledge acquisition. It was, however, inversely related to state anxiety so that the higher post-session state anxiety, the lower the AC's decisional conflict.

Conclusion

Numeracy and health literacy are associated with learning of orally communicated information during genetic counseling. It appears that numeracy can facilitate learning for literate subjects; it does not, however, make any difference in learning ability of clients with significant literacy deficits.

Practice implications

Numeracy plays an important role in client's ability to learn information communicated during medical sessions, especially among clients who are otherwise regarded as literate.     

Validation of a combined health literacy and numeracy instrument for patients with type 2 diabetes

Objectives

This study aimed to validate a new consolidated measure of health literacy and numeracy (health literacy scale [HLS] plus the subjective numeracy scale [SNS]) in patients with type 2 diabetes (T2DM).

Randomized comparison of selective serotonin reuptake inhibitor (escitalopram) monotherapy and antidepressant combination pharmacotherapy for major depressive disorder with melancholic features: a CO-MED report

Background

The clinical effects of antidepressant combinations vs. monotherapy as initial treatment for major depression with melancholic features (MDD-MF) are unknown.

Methods

Outpatients with chronic or recurrent major depression (MDD) were randomized to initial treatment with escitalopram + placebo (the MONO condition), bupropion-sustained release + escitalopram, or venlafaxine-extended release + mirtazapine (the COMB conditions) in the Combining Medications to Enhance Depression Outcomes (CO-MED) trial. Secondary data analyses were conducted to compare demographic and clinical characteristics, and contrast clinical responses according to drug treatment, in patients with MDD-MF (n = 124) and non-melancholic MDD (n = 481).

Results

While numerically lower, remission rates in MDD-MF did not differ significantly from those with non-melancholic MDD either at 12 (33.1% vs. 41.0%, aOR 1.16, p = 0.58) or 28 (39.5% vs. 46.8%, aOR = 1.02, p = 0.93) weeks of treatment. Remission rates did not differ significantly between combination and monotherapy groups in either MDD-MF or non-melancholic MDD patients at either time point. Similar conclusions were reached for response rates, premature study discontinuation, and self-rated depression symptom severity.

Limitations

This is a secondary analysis of data from the CO-MED trial, which was not designed to address differential treatment response in melancholic and non-melancholic MDD.

Conclusions

We found no evidence of differential remission or response rates to antidepressant combination or monotherapy between melancholic/non-melancholic MDD patients, or according to antidepressant treatment group, after 12 and 28 weeks. Melancholic features may not be a valid predictor of more favorable response to antidepressant combination therapy as initial treatment.