Anjali U. Pandit

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: beta=-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.

Disease-related distress, self-care and clinical outcomes among low-income patients with diabetes

Background The purpose of this study is to determine the prevalence of diabetes distress and its relationship with health behaviours and clinical outcomes in low-income patients. Methods Secondary analyses were conducted using baseline data from a clinical trial evaluating a diabetes self-management intervention. Interviews were conducted with 666 participants receiving care at nine safety net clinics in Missouri. Distress was measured using the Diabetes Distress Scale, and outcomes included medication adherence, physical activity, nutrition and clinical biomarkers (haemoglobin A1C (HbA1C), blood pressure, low-density lipoprotein (LDL) cholesterol). Results In a sample of 666 participants, 14.1% and 27.3% of patients were identified as highly and moderately distressed, respectively, with higher rates among younger, female and lower income patients. When compared with moderately and no distress groups, highly distressed patients were less adherent to medications (20.7% vs 29.9% vs 39.4%, p<0.001) and had higher HbA1C values (9.3% (SD=2.0) vs 8.2% (SD=1.8) vs 7.8% (SD=1.7), p<0.001), diastolic blood pressure (81.8 (SD=9.4) vs 80.2 (9.7) vs 78.9 (SD=8.8), p=0.02) and LDL cholesterol (104.6 (SD=42.4) vs 97.2 (34.3) vs 95.5 (37.9)) In multivariable analyses, high and moderate distress were associated with lower medication adherence (OR=0.44; 0.27 to 0.23, p=0.001) and (OR=0.58; 0.42 to 0.79; p=0.001), respectively, and higher HbA1C in only the highly distressed group (B=1.3; 0.81 to 1.85; p<0.001) compared with the no distress group. Conclusions Diabetes distress is prevalent and linked to poorer adherence to health behaviours and glycemic control in a sample of patients receiving care from low-income clinics.

Availability of Spanish Prescription Labels: A Multi-state Pharmacy Survey

Background:Patient misunderstanding of prescription drug label instructions is a leading cause of medication errors. Among Latino patients, limited English proficiency is a major barrier to comprehension of medication instructions. Objectives:To determine the availability of Spanish prescription drug label instructions. Research Design:A telephone survey was conducted in 4 states selected due to either a rapid growth in their Latino population (GA, NC) or a large, existing Latino population (CO, TX). Subjects:A list of retail pharmacies was obtained from each state board of pharmacy. A simple random sample of 10 percent of pharmacies within each state was generated (N = 764). Measures:The ability of pharmacies to print prescription instructions in Spanish and the process for translating instructions. Results:Two hundred sixty-seven (34.9%) pharmacies reported no translation services, 166 (21.7%) reported limited translation services, and 331 (43.3%) stated they were able to perform translations. In bivariate analyses, significant differences between pharmacy characteristics and the availability of Spanish labels were noted. In multivariate analysis including pharmacy type, location, percentage Latino population, and state, only metropolitan location was found to be a significant independent predictor of pharmacies offering full Spanish translation services (adjusted odds ratio: 1.72, 95% confidence interval: 1.04–2.84). Conclusions:The majority of pharmacies surveyed offered limited or no translation services. Lack of translation services is not isolated to rural areas or locations with a marginal Latino population. Spanish-speaking patients encounter barriers to acquiring instructions that support the safe and effective use of medications.

The availability, functionality, and quality of mobile applications supporting medication self-management.

OBJECTIVE To systematically review mobile applications currently available to patients to support outpatient medication self-management. METHODS Three online stores were searched in March 2013 using nine distinct search terms. Applications were selected if they supported general outpatient medication self-management for adults; they were excluded if they focused on only one medication or condition, provided only a medication list or reference, only ordered refills, were written in a non-English language, or were for local pharmacy/hospital patients only. A multi-step review process was utilized by two independent reviewers to identify eligible applications. A standardized form was used to abstract data. User reviews were compiled from a subsample of applications and qualitatively coded to identify common criticisms. RESULTS 14,893 applications were initially identified. After the multi-step review process, 424 applications were deemed eligible for inclusion by reviewers (κ=0.85). On average, applications were rated 2.8 stars (out of 5) from 107 reviews. Almost all provided medication reminders (91.0%), half enabled patients to create a medication history or log (51.5%), and 22% could email the log to a third party. Few helped patients organize their regimen (6.2%), check for drug interactions (2.8%), or identify pills (4.0%). User reviews (N=1091) from the subsample of 26 applications revealed common criticisms, including technical malfunctions, poor compatibility with certain medications, and absence of desired features. CONCLUSIONS Hundreds of applications exist in the marketplace to support medication self-management. However, their quality, content, and functionality are highly variable. Research is needed to determine optimal capabilities, evaluate utility, and determine clinical benefit.

Factors associated with patient understanding of preeclampsia.

Objective. To explore the extent to which pregnant women understand the symptoms and potential complications related to preeclampsia and to determine the factors that are associated with better understanding. Methods. This was a cross-sectional study in which 112 pregnant patients were interviewed to determine their preeclampsia knowledge. Knowledge was evaluated using a 25-item survey addressing the symptoms, consequences, and proper patient actions associated with preeclampsia. Patients were also asked in an open-ended question to define preeclampsia; all responses were rated by three obstetricians. Information about demographics, medical and obstetrical history, and health literacy was also obtained. Health literacy was assessed using the short Test of Functional Health Literacy in Adults (S-TOFHLA). Results. Patients correctly answered only 43% of the 25 questions assessing preeclampsia knowledge. Moreover, only 14% of the patients were able to provide a definition that correctly reflected the syndrome. Factors associated with a greater proportion of correct answers on the questionnaire were higher literacy, multiparity, history of preeclampsia, and receipt of information about preeclampsia from a clinician or another information source (e.g., the Internet, television, a book, or a friend). Conclusions. Pregnant patients have a generally poor understanding of preeclampsia, although improved understanding is associated with having received information about the disease. Further investigation will be needed to determine how best to educate patients and whether this education can also decrease adverse outcomes associated with this syndrome.

The association between patient activation and accessing online health information: Results from a national survey of US adults

There are increasing opportunities for the public to access online health information, but attitudinal barriers to use are less well‐known. Patient activation is associated with key health outcomes, but its relationship with using online health information is not known.

The Role of Patient Activation in Preferences for Shared Decision Making: Results From a National Survey of U.S. Adults

Studies investigating preferences for shared decision making (SDM) have focused on associations with sociodemographic variables, with few investigations exploring patient factors. We aimed to investigate the relationship between patient activation and preferences for SDM in 6 common medical decisions among a nationally representative cross-sectional survey of American adults. Adults older than 18 were recruited online (n = 2,700) and by telephone (n = 700). Respondents completed sociodemographic assessments and the Patient Activation Measure. They were also asked whether they perceived benefit (yes/no) in SDM in 6 common medical decisions. Nearly half of the sample (45.9%) reached the highest level of activation (Level 4). Activation was associated with age (p < .001), higher income (p = .001), higher education (p = .010), better self-rated health (p < .001), and fewer chronic conditions (p = .050). The proportion of people who agreed that SDM was beneficial varied from 53.1% (deciding the necessity of a diagnostic test) to 71.8% (decisions associated with making lifestyle changes). After we controlled for participant characteristics, higher activation was associated with greater perceived benefit in SDM across 4 of the 6 decisions. Preferences for SDM varied among 6 common medical scenarios. Low patient activation is an important barrier to SDM that could be ameliorated through the development of behavioral interventions.

Development and Validation of the Consumer Health Activation Index

Background. Although there has been increasing interest in patient engagement, few measures are publicly available and suitable for patients with limited health literacy. Objective. We sought to develop a Consumer Health Activation Index (CHAI) for use among diverse patients. Methods. Expert opinion, a systematic literature review, focus groups, and cognitive interviews with patients were used to create and revise a potential set of items. Psychometric testing guided by item response theory was then conducted among 301 English-speaking, community-dwelling adults. This included differential item functioning analyses to evaluate item performance across participant health literacy levels. To determine construct validity, CHAI scores were compared to scales measuring similar personality constructs. Associations between the CHAI and physical and mental health established predictive validity. A second study among 9,478 adults was used to confirm CHAI associations with health outcomes. Results. Exploratory factor analyses revealed a single-factor solution with a 10-item scale. The CHAI showed good internal consistency (alpha = 0.81) and moderate test–retest reliability (ICC = 0.53). Reading grade level was found to be at the 6th grade. Moderate to strong correlations were found with similar constructs (Multidimensional Health Locus of Control, r = 0.38, P < 0.001; Conscientiousness, r = 0.41, P < 0.001). Predictive validity was demonstrated through associations with functional health status measures (depression, r = −0.28, P < 0.001; anxiety, r = −0.22, P < 0.001; and physical functioning, r = 0.22, P < 0.001). In the validation sample, the CHAI was significantly associated with self-reported physical and mental health (r = 0.31 and 0.32 respectively; both P < 0.001). Conclusions. The CHAI appears to be a valid, reliable, and easily administered tool that can be used to assess health activation among adults, including those with limited health literacy. Future studies should test the tool in actual use and explore further applications.

Translating clinical evidence to the community: a synopsis and comment on "Community wide interventions for increasing physical activity".

The third column on Evidence-Based Behavioral Medicine is focused on the Baker et al. Cochrane Review entitled “Community wide interventions for increasing physical activity.” We provide a synopsis of the review as well as a comment on the future direction of community-wide physical activity interventions.