Ann C. Haas

Literacy Skills and Calculated 10-Year Risk of Coronary Heart Disease

BackgroundCoronary heart disease (CHD) is a leading cause of morbidity and mortality. Reducing the disease burden requires an understanding of factors associated with the prevention and management of CHD. Literacy skills may be one such factor.ObjectivesTo examine the independent and interactive effects of four literacy skills: reading, numeracy, oral language (speaking) and aural language (listening) on calculated 10-year risk of CHD and to determine whether the relationships between literacy skills and CHD risk were similar for men and women.DesignWe used multivariable linear regression to assess the individual, combined, and interactive effects of the four literacy skills on risk of CHD, adjusting for education and race.ParticipantsFour hundred and nine English-speaking adults in Boston, MA and Providence, RI.MeasuresTen-year risk of coronary heart disease was calculated using the Framingham algorithm. Reading, oral language and aural language were measured using the Woodcock Johnson III Tests of Achievement. Numeracy was assessed through a modified version of the numeracy scale by Lipkus and colleagues.Key ResultsWhen examined individually, reading (p = 0.007), numeracy (p = 0.001) and aural language (p = 0.004) skills were significantly associated with CHD risk among women; no literacy skills were associated with CHD risk in men. When examined together, there was some evidence for an interaction between numeracy and aural language among women suggesting that higher skills in one area (e.g., aural language) may compensate for difficulties in another resulting in an equally low risk of CHD.ConclusionsResults of this study not only provide important insight into the independent and interactive effects of literacy skills on risk of CHD, they also highlight the need for the development of easy-to use assessments of the oral exchange in the health care setting and the need to better understand which literacy skills are most important for a given health outcome.

Patient Activation and Advocacy: Which Literacy Skills Matter Most?

Attention to the effect of a patients literacy skills on health care interactions is relatively new. So, too, are studies of either structural or personal factors that inhibit or support a patients ability to navigate health services and systems and to advocate for their own needs within a service delivery system. Contributions of the structural environment, of interpersonal dynamics, and of a variety of psychological and sociological factors in the relationship between patients and providers have long been under study. Less frequently examined is the advocacy role expected of patients. However, the complex nature of health care in the United States increasingly requires a proactive stance. This study examined whether four literacy skills (reading, numeracy, speaking, and listening) were associated with patient self-advocacy—a component of health literacy itself—when faced with a hypothetical barrier to scheduling a medical appointment. Although all literacy skills were significantly associated with advocacy when examined in isolation, greater speaking and listening skills remained significantly associated with better patient advocacy when all four skills were examined simultaneously. These findings suggest that speaking and listening skills and support for such skills may be important factors to consider when developing patient activation and advocacy skills.

Predictors of the Existence of Congregational HIV Programs: Similarities and Differences Compared With Other Health Programs

Purpose. Identify and compare predictors of the existence of congregational human immunodeficiency virus (HIV) and other health programs. Design. Cross-sectional study. Setting. United States. Subjects. A nationally representative sample of 1506 U.S. congregations surveyed in the National Congregations Study (2006–2007). Measures. Key informants at each congregation completed in-person and telephone interviews on congregational HIV and other health programs and various congregation characteristics (response rate = 78%). County-level HIV prevalence and population health data from the Robert Wood Johnson Foundations 2007 County Health Rankings were linked to the congregational data. Analysis. Multinomial logistic regression was used to assess factors that predict congregational health programs relative to no health programs; and of HIV programs relative to other health activities. Results. Most congregations (57.5%) had at least one health-related program; many fewer (5.7%) had an HIV program. Predictors of health vs. HIV programs differed. The number of adults in the congregation was a key predictor of health programs, while having an official statement welcoming gay persons was a significant predictor of HIV programs (p < .05). Other significant characteristics varied by size of congregation and type of program (HIV vs. other health). Conclusion. Organizations interested in partnering with congregations to promote health or prevent HIV should consider congregational size as well as other factors that predict involvement. Results of this study can inform policy interventions to increase the capacity of religious congregations to address HIV and health.

Which literacy skills are associated with smoking

Background Research has demonstrated associations between smoking and reading skills, but other literacy skills such as speaking, listening and numeracy are less studied despite our dependence on the use of numbers and the oral exchange to deliver information on the risks of smoking. Methods The authors used multivariable logistic regression to examine the effects of reading, numeracy, speaking and listening skills on: (1) becoming a regular smoker and (2) smoking cessation. Further, multivariable linear regression was used to examine the relation between literacy skills and amount smoked among current smokers. Models controlled for education, gender, age, race/ethnicity, income and, when relevant, age at which they became a regular smoker. Results For each grade equivalent increase in reading skills, the odds of quitting smoking increased by about 8% (OR=1.08, 95% CI 1.01 to 1.15). For every point increase in numeracy skills, the odds of quitting increased by about 24% (OR=1.24, 95% CI 1.06 to 1.46). No literacy skills were associated with becoming a regular smoker or current amount smoked. Conclusion The ability to locate, understand and use information related to the risks of smoking may impact ones decision to quit. Messaging should be designed with the goal of being easily understood by all individuals regardless of literacy level.

A Retrospective Evaluation of the Perfecting Patient Care University Training Program for Health Care Organizations

This study evaluated how the Perfecting Patient Care (PPC) University, a quality improvement (QI) training program for health care leaders and clinicians, affected the ability of organizations to improve the health care they provide. This training program teaches improvement methods based on Lean concepts and principles of the Toyota Production System and is offered in several formats. A retrospective evaluation was performed that gathered data on training, other process factors, and outcomes after staff completed the PPC training. A majority of respondents reported gaining QI competencies and cultural achievements from the training. Organizations had high average scores for the success measures of “outcomes improved” and “sustainable monitoring” but lower scores for diffusion of QI efforts. Total training dosage was significantly associated with the measures of QI success. This evaluation provides evidence that organizations gained the PPC competencies and cultural achievements and that training dosage is a driver of QI success.

Less Use of Extreme Response Options by Asians to Standardized Care Scenarios May Explain Some Racial/Ethnic Differences in CAHPS Scores

Background:Asian Americans (hereafter “Asians”) generally report worse experiences with care than non-Latino whites (hereafter “whites”), which may reflect differential use of response scales. Past studies indicate that Asians exhibit lower Extreme Response Tendency (ERT)—they less frequently use responses at extreme ends of the scale than whites. Objective:To explore whether lower ERT is observed for Asians than whites in response to standardized vignettes depicting patient experiences of care and whether ERT might in part explain Asians reporting worse care than whites. Procedure:A representative US sample (n=575 Asian; n=505 white) was presented with 5 written vignettes describing doctor-patient encounters with differing levels of physician responsiveness. Respondents evaluated the encounters using modified CAHPS communication questions. Results:Case-mix–adjusted repeated-measures multivariate models show that Asians provided more positive responses than whites to several vignettes with less-responsive physicians but less positive responses than whites for the vignette with the most physician responsiveness (P<0.01 for each). While all respondents provided more positive ratings for vignettes with greater physician responsiveness, the increase was 15% less for Asian than white respondents. Conclusions:Asians exhibit lower ERT than whites in response to standardized scenarios. Because CAHPS reponses are predominantly near the positive end of the scale and the most responsive scenario is most typical of the score observed in real-world settings, lower ERT in Asians may partially explain observations of lower observed mean CAHPS scores for Asians in real-world settings. Case-mix adjustment for Asian race/ethnicity or its correlates may improve quality of care measurement.

Erratum to: Correlates of HIV Testing among African American and Latino Church Congregants: The Role of HIV Stigmatizing Attitudes and Discussions about HIV

Faith-based organizations can be key settings in which to reach African Americans and Latinos for HIV prevention, but little is known regarding factors that predict congregants’ HIV testing behaviors. We examined the extent to which sociodemographic factors, HIV-related cues to action (e.g., knowing someone who is HIV-positive), and the social climate surrounding HIV (stigma toward a hypothetical HIV-positive congregant, HIV-related discussions at church about abstinence, condoms, and testing) were associated with willingness to be tested in church and with ever having been tested among 1211 African American and Latino congregants. Multivariate analyses indicated that congregants were more open to church-based testing if they were younger and had discussed condoms at church. They were less open if they expressed stigmatizing attitudes toward a hypothetical congregant. Foreign-born Latinos with low English proficiency were more willing to be tested at church than were African Americans. Congregants were more likely to have ever been tested if they were younger, African American, female, or married; if they knew someone who was HIV-positive; and if they had discussed testing and condoms at church. They were less likely if they had discussed abstinence. Open dialogue around HIV may activate congregants to be more receptive to church-based prevention.

Measuring success for health care quality improvement interventions.

Background:The lack of a standard measure of quality improvement (QI) success and the use of subjective or self-reported measures of QI success has constrained efforts to formally evaluate QI programs and to understand how the various contextual factors impact QI success. Objectives:The objective of this study was to assess how best to measure “QI success” by comparing self-reported and externally rated measures of QI success. Research Design:We performed a retrospective evaluation that analyzed data on different measures of QI success for organizations after their staff completed the QI training. Subjects:The sample included 30 organizations whose staff had received QI training during 2006–2008, and who had used this training to carry out at least some subsequent QI initiative in their organizations. Measures:We developed 2 measures of self-reported QI success based on survey responses and 4 externally rated measures of QI success based on outcome data provided by the participating organizations in addition to qualitative data generated from the interviews. Results:We found some variation in the mean scores of the different QI success measures and only moderate to small correlations between the self-report and externally rated QI measures. Conclusions:This study confirms that there are important differences between self-reported and externally rated measures of QI success and provides researchers with a methodology and criteria to externally rate measures of QI success.

Prevalence and consequences of sleep problems in military wives

STUDY OBJECTIVES Despite the prevalence of sleep problems among service members, few prior studies have examined the rate of sleep problems among military spouses, who also face the stresses of deployment and military life. This is the first study of spouses of US service members to examine the prevalence of sleep disturbances, effect of service member deployment, and associated physical and psychosocial outcomes. DESIGN Cross-sectional analysis of RAND Deployment Life Study data. SETTING Self-report measures administered via telephone and web-based surveys in Fall 2012. PARTICIPANTS Female military spouses (n = 1805) aged 19 to 65 years (M = 33.5 [8.3]), married to service members across branches and components (73% previously, 10% currently, and 16% never deployed). MEASUREMENTS Spouses self-reported sleep duration, sleep quality, daytime fatigue, and daytime impairment. Outcomes included self-rated health, marital satisfaction, and depressive symptoms. RESULTS Eighteen percent of spouses reported extreme short sleep duration, which is higher than rates reported in the general population. Spouses indicated worse sleep when the service member was currently or previously deployed, although deployment status was not associated with sleep duration or daytime impairment. Greater sleep disturbances were significantly associated with all three outcomes, with the strongest association observed with greater depressive symptoms. CONCLUSIONS This is the first report to document high rates of short sleep duration and poor sleep quality among spouses of service members. Furthermore, sleep problems were independent correlates of poor mental and physical health. Findings highlight the importance of addressing sleep issues in military families as well as in service members.

Church-Based HIV Screening in Racial/Ethnic Minority Communities of California, 2011-2012

Community-based human immunodeficiency virus (HIV) testing at religious congregations has been proposed as a potentially effective way to increase screening among disproportionately affected populations, such as those self-identifying as African American and Latino. Although congregations may provide reach into these communities, the extent to which church-based HIV testing alleviates access barriers, identifies new cases, and reaches people at increased risk for HIV is not well documented. We examined the results of an HIV testing program that was conducted as part of a larger intervention aimed at reducing HIV stigma at five churches in Los Angeles County, California, in 2011-2012. HIV screening identified one positive result in 323 tests but reached a substantial proportion of people who had not been tested before, including many who lacked health insurance. Although this approach may not be an efficient way to identify cases of previously unknown HIV infection, it could help achieve universal testing goals.