Elizabeth A.H. Wilson

Literacy and Learning in Health Care

The relationship between literacy and health outcomes are well documented in adult medicine, yet specific causal pathways are not entirely clear. Despite an incomplete understanding of the problem, numerous interventions have already been implemented with variable success. Many of those who proposed earlier strategies assumed the problem to originate from reading difficulties only. Given the timely need for more effective interventions, it is of increasing importance to reconsider the meaning of health literacy to advance our conceptual understanding of the problem and how best to respond. One potentially effective approach might involve recognizing the known associations between a larger set of cognitive and psychosocial abilities with functional literacy skills. Here we review the current health literacy definition and literature and draw on relevant research from the fields of education, cognitive science, and psychology. In this framework, a research agenda is proposed that considers an individuals “health-learning capacity,” which refers to the broad constellation of cognitive and psychosocial skills from which patients or family members must draw to effectively promote, protect, and manage their own or a childs health. This new, related concept will lead, ideally, to more effective ways of thinking about health literacy interventions, including the design of health-education materials, instructional strategies, and the delivery of health care services to support patients and families across the life span.

Comparative analysis of print and multimedia health materials: A review of the literature

OBJECTIVE Evaluate the evidence regarding the relative effectiveness of multimedia and print as modes of dissemination for patient education materials; examine whether development of these materials addressed health literacy. METHODS A structured literature review utilizing Medline, PsycInfo, and the Cumulative Index to the Nursing and Allied Health Literature (CINAHL), supplemented by reference mining. RESULTS Of 738 studies screened, 30 effectively compared multimedia and print materials. Studies offered 56 opportunities for assessing the effect of medium on various outcomes (e.g., knowledge). In 30 instances (54%), no difference was noted between multimedia and print in terms of patient outcomes. Multimedia led to better outcomes vs. print in 21 (38%) comparisons vs. 5 (9%) instances for print. Regarding material development, 12 studies (40%) assessed readability and 5 (17%) involved patients in tool development. CONCLUSIONS Multimedia appears to be a promising medium for patient education; however, the majority of studies found that print and multimedia performed equally well in practice. Few studies involved patients in material development, and less than half assessed the readability of materials. PRACTICE IMPLICATIONS Future research should focus on comparing message-equivalent tools and assessing their effect on behavioral outcomes. Material development should include explicit attention to readability and patient input.

Depressive Symptoms, Low Adherence, and Poor Asthma Outcomes in the Elderly

Objective. To examine the impact of depressive symptoms on asthma outcomes and medication adherence in inner-city elderly patients with asthma. Methods. Cohort study of elderly asthmatics receiving primary care at three clinics in New York City and Chicago from 1 January 2010 to 1 January 2012. Depressive symptoms were ascertained with the Patient Health Questionnaire (PHQ-9). Outcomes included asthma control (Asthma Control Questionnaire, ACQ), asthma-related quality of life (Asthma Quality of Life Questionnaire, AQLQ), and acute resource utilization (inpatient and outpatient visits). Asthma medication adherence was evaluated using the Medication Adherence Reporting Scale (MARS). Results. Three hundred and seventeen participants ≥60 years were included in the study (83% women, 30% Hispanic, and 31% Black). In unadjusted analyses, participants with depressive symptoms were more likely to report poor asthma control (p < .001), worse AQLQ scores (p < .001), and higher rates of inpatient asthma-related visits (odds ratio [OR]: 2.03, 95% confidence interval [CI]: 1.04–3.99). Those with depressive symptoms also reported lower medication adherence (OR: 0.23, 95%CI: 0.10–0.54). Similar results were obtained in analyses adjusting for age, sex, race/ethnicity, income, asthma medication prescription, years with asthma, intubation history, comorbidities, and health literacy. Conclusion. In this cohort of elderly inner-city participants, depressive symptoms were associated with poorer asthma control and quality of life, as well as with lower rates of adherence to controller medications. Future work exploring possible mediators, including adherence, might elucidate the relationship between depression and poorer asthma outcomes in this population.

Literacy and race as risk factors for low rates of advance directives in older adults.

To examine the effect of the relationship between literacy and other individual‐level factors on having an advance directive (AD).

The Influence of Health Literacy on Comprehension of a Colonoscopy Preparation Information Leaflet

BACKGROUND: Successful bowel preparation is important for safe, efficacious, cost-effective colonoscopy procedures; however, poor preparation is common. OBJECTIVE: We sought to determine whether there was an association between health literacy and comprehension of typical written instructions on how to prepare for a colonoscopy to enable more targeted interventions in this area. DESIGN: This is a cross-sectional observational study. SETTING: This study was performed at primary care clinics and federally qualified health centers in Chicago, Illinois. PATIENTS: Seven hundred sixty-four participants (mean age, 63 years; SD, 5.42) were recruited. The sample was from a mixed sociodemographic background, and 71.9% of the participants were classified as having adequate health literacy scores. INTERVENTION: Seven hundred sixty-four participants were presented with an information leaflet outlining the bowel preparatory instructions for colonoscopy. MAIN OUTCOME MEASURES: Five questions were used to assess participants’ comprehension of the instructions in an “open book” test. RESULTS: Comprehension scores on the bowel preparation items were low. The mean number of items correctly answered was 3.2 (SD, 1.2) of a possible 5. Comprehension scores overall and for each individual item differed significantly by health literacy level (all p < 0.001). After controlling for sex, age, race, socioeconomic status, and previous colonoscopy experience in a multivariable model, health literacy was a significant predictor of comprehension (inadequate vs adequate: &bgr; = −0.2; p < 0.001; marginal vs adequate: &bgr; = −0.2; p < 0.001). LIMITATIONS: The outcome represents a simulated task and not actual comprehension of preparation instructions for participants’ own recommended behavior. CONCLUSIONS: Comprehension of a written colonoscopy preparation leaflet was generally low and significantly lower among people with low health literacy. Poor comprehension has implications for the safety and economic impact of gastroenterological procedures such as colonoscopy. Therefore, future interventions should aim to improve comprehension of complex medical information by reducing literacy-related barriers.

The association between language proficiency and outcomes of elderly patients with asthma

BACKGROUND Asthma is a growing cause of morbidity for elderly Americans and is highly prevalent among Hispanic people in the United States. The inability to speak English poses a barrier to patient-provider communication. OBJECTIVE To evaluate associations between limited English proficiency, asthma self-management, and outcomes in elderly Hispanic patients. METHOD Elderly patients with asthma receiving primary care at clinics in New York City and Chicago were studied. RESULTS Of 268 patients in the study, 68% were non-Hispanic, 18% English-proficient Hispanic, and 14% Hispanic with limited English proficiency. Unadjusted analyses showed that Hispanic persons with limited English proficiency had worse asthma control (P = .0007), increased likelihood of inpatient visits (P = .002), and poorer quality of life (P < .0001). We also found significant associations between limited English proficiency and poorer medication adherence (P = .006). Similar results were obtained in multiple regression analyses adjusting for demographics, asthma history, comorbidities, depression, and health literacy. CONCLUSION Limited English proficiency was associated with poorer self-management and worse outcomes among elderly patients with asthma. Further understanding of mechanisms underlying this relationship is necessary to develop interventions that improve asthma outcomes in this vulnerable population.

The association of health literacy with illness and medication beliefs among older adults with asthma.

OBJECTIVE Suboptimal health literacy (HL) and asthma beliefs are associated with poor asthma self-management and outcomes. We tested the hypothesis that low HL is associated with inaccurate beliefs. METHODS Asthmatics ≥60 were recruited from hospital and community practices in New York, NY and Chicago, IL (n=420). HL was measured with the Short Test of Functional Health Literacy in Adults; validated instruments derived from the self regulation model were used to assess beliefs. The association of beliefs with HL was evaluated with multivariate models. RESULTS Thirty-six percent of patients had low HL; 54% believed they only have asthma when symptoms are present, 29% believed they will not always have asthma and 20% believed that their doctor can cure asthma. HL was associated with beliefs of not having asthma all the time and that asthma can be cured (OR: 1.84, 95% CI: 1.2-2.82; OR: 2.22, 95% CI: 1.29-3.82, respectively). Patients with low HL were also more likely to be concerned about medication use (β=0.92, p=.05), despite recognizing their necessity (β=-1.36, p=.01). CONCLUSIONS Older asthmatics with low HL endorse erroneous asthma beliefs. PRACTICE IMPLICATIONS Health communications for improving self-management behaviors in asthma should employ both health literacy-appropriate strategies and messages to counter illness-related misconceptions.

The evolving field of health literacy research.

We are quite pleased to present the current special issue on Health Literacy of the Journal of Health Communication. We hope readers will see this issue as a marker of the Journal’s long-term interest and commitment to health literacy research and as an exhibit of the rapidly evolving field of health literacy. This issue presents findings from the first Health Literacy Annual Research Conference (HARC) which took place in October 2009 at the National Academy of Sciences Building, Washington, DC. HARC is an interdisciplinary meeting for investigators dedicated to health literacy research. Our aim is to attract a full range of investigators engaged in health literacy research including those involved in a broad array of public health, health services, epidemiology, translational, and interventional research activities.

An EMR-based tool to support collaborative planning for medication use among adults with diabetes: design of a multi-site randomized control trial.

Patients with type II diabetes often struggle with self-care, including adhering to complex medication regimens and managing their blood glucose levels. Medication nonadherence in this population reflects many factors, including a gap between the demands of taking medication and the limited literacy and cognitive resources that many patients bring to this task. This gap is exacerbated by a lack of health system support, such as inadequate patient-provider collaboration. The goal of our project is to improve self-management of medications and related health outcomes by providing system support. The Medtable™ is an Electronic Medical Record (EMR)-integrated tool designed to support patient-provider collaboration needed for medication management. It helps providers and patients work together to create effective medication schedules that are easy to implement. We describe the development and initial evaluation of the tool, as well as the process of integrating it with an EMR system in general internal medicine clinics. A planned evaluation study will investigate whether an intervention centered on the Medtable™ improves medication knowledge, adherence, and health outcomes relative to a usual care control condition among type II diabetic patients struggling to manage multiple medications.

Development and Validation of the Comprehensive Health Activities Scale: A New Approach to Health Literacy Measurement

Current health literacy measures have been criticized for solely measuring reading and numeracy skills when a broader set of skills is necessary for making informed health decisions, especially when information is often conveyed verbally and through multimedia video. The authors devised 9 health tasks and a corresponding 190-item assessment to more comprehensively measure health literacy skills. A sample of 826 participants between the ages of 55 and 74 years who were recruited from an academic general internal medicine practice and three federally qualified health centers in Chicago, Illinois, completed the assessment. Items were reduced using hierarchical factor analysis and item response theory resulting in the 45-item Comprehensive Health Activities Scale. All 45 items loaded on 1 general latent trait, and the resulting scale demonstrated high reliability and strong construct validity using measures of health literacy and global cognitive functioning. The predictive validity of the Comprehensive Health Activities Scale using self-reported general, physical, and mental health status was comparable to or better than widely used measures of health literacy, depending on the outcome. Despite comprehensively measuring health literacy skills, items in the Comprehensive Health Activities Scale supported 1 primary construct. With similar psychometric properties, current measures may be adequate, depending on the purpose of the assessment.