Joanne E. Jordan

Critical appraisal of health literacy indices revealed variable underlying constructs, narrow content and psychometric weaknesses

OBJECTIVE Health literacy refers to an individuals ability to seek, understand, and use health information. A range of indices exist that purport to measure health literacy across individuals and populations. This study aimed to review the development and content of existing indices and to critically appraise their properties. STUDY DESIGN AND SETTING Using standardized search terms, published generic health literacy indices (1990-2008) were identified. Using a methodological framework, each was evaluated for purpose, validity (face, content, construct), reliability, responsiveness, feasibility, and generalizability. RESULTS Nineteen instruments were evaluated. Three measurement approaches were identified: direct testing of individual abilities, self-report of abilities, and population-based proxy measures. Composition of underlying constructs and content varied widely across instruments, and none appeared to fully measure a persons ability to seek, understand, and use health information. The content was focused primarily on reading comprehension and numeracy; scoring categories were poorly defined and may not be mutually exclusive, and few indices had been assessed for reliability. CONCLUSION Health literacy is not consistently measured, making it difficult to interpret and compare health literacy at individual and population levels. Empirical evidence demonstrating validity and reliability of existing indices is required, and more comprehensive health literacy instruments need to be developed.

Conceptualising health literacy from the patient perspective

OBJECTIVE A persons health literacy, i.e., their ability to seek, understand and use health information, is a critical determinant of whether they are able to actively participate in their healthcare. The objective of this study was to conceptualise health literacy from the patient perspective. METHODS Using comprehensive qualitative methods 48 individuals were interviewed across three distinct groups in Australia: those with a chronic condition, the general community and individuals who had recently presented to a metropolitan public hospital emergency department. Purposeful sampling was employed to ensure a range of experiences was captured. RESULTS Seven key abilities were identified: knowing when to seek health information; knowing where to seek health information; verbal communication skills; assertiveness; literacy skills; capacity to process and retain information; application skills. CONCLUSION This study identifies key abilities patients identified as critical to seek, understand and utilise information in the healthcare setting. These abilities are not reflected in existing measures for health literacy. Future measures of health literacy could consider incorporating abilities identified in this study and may provide guidance in developing health interventions to assist patients to participate effectively in their health. PRACTICE IMPLICATIONS More comprehensive measures to assess patients health literacy are needed.

HEALTH LITERACY AND BELIEFS AMONG A COMMUNITY COHORT WITH AND WITHOUT CHRONIC LOW BACK PAIN

&NA; Health literacy, the ability to seek, understand and utilise health information, is important for good health. Suboptimal health literacy has been associated with poorer health outcomes in many chronic conditions although this has not been studied in chronic low back pain (CLBP). We examined the health literacy of individuals with CLBP using a mixed methods approach. One‐hundred and seventeen adults, comprising 61 with no history of CLBP and 56 with CLBP (28 with low and high disability, respectively, as determined by a median split in Oswestry scores) participated. Data regarding severity of pain, LBP‐related disability, fear avoidance, beliefs about LBP and pain catastrophizing were collected using questionnaires. Health literacy was measured using the Short‐form Test of Functional Health Literacy in Adults (S‐TOFHLA). A sub‐sample of 36 participants with CLBP also participated in in‐depth interviews to qualitatively explore their beliefs about LBP and experiences in seeking, understanding and using information related to LBP. LBP‐related beliefs and behaviours, rather than pain intensity and health literacy skills, were found to be important correlates of disability related to LBP. Individuals with CLBP‐high disability had poorer back pain beliefs and increased fear avoidance behaviours relating to physical activity. Health literacy (S‐TOFHLA) was not related to LBP beliefs and attitudes. Qualitatively, individuals with CLBP‐high disability adopted a more passive coping style and had a pathoanatomic view of their disorder compared to individuals with CLBP‐low disability. While all participants with CLBP had adequate health literacy scores (S‐TOFHLA), qualitative data highlighted difficulties in seeking, understanding and utilising LBP information.

The health literacy management scale (HeLMS): a measure of an individual's capacity to seek, understand and use health information within the healthcare setting.

OBJECTIVE Health literacy refers to an individuals ability to seek, understand, and use health information. This paper describes the development and psychometric testing of the health literacy management scale (HeLMS). METHODS Content areas were identified from a conceptual framework derived from interviews and concept mapping. Items were generated from statements from concept mapping participants. Construction (N=333) and replication (N=350) samples were participants in chronic disease self-management programs and emergency department attendees. Factor analysis was used to refine constructs and define psychometric properties. RESULTS Consultations generated 8 scales each with 4-5 items: Understanding health information, Accessing GP healthcare services, Communication with health professionals, Being proactive and Using health information, Patient attitudes towards their health, Social support, and Socioeconomic considerations. Confirmatory factor analyses indicated good fit of the data with the model (RMSEA=0.07, SRMR=0.05, CFI=0.97) and all domains had high internal consistency (Cronbach alpha>0.82). CONCLUSION The HeLMS has acceptable psychometric properties and assesses a range of health literacy constructs important to patients when seeking, understanding and using health information within the healthcare system. PRACTICE IMPLICATIONS The HeLMS presents a new approach to assessing health literacy in healthcare settings.

Consumers’ experiences of back pain in rural Western Australia: access to information and services, and self-management behaviours

BackgroundCoordinated, interdisciplinary services, supported by self-management underpin effective management for chronic low back pain (CLBP). However, a combination of system, provider and consumer-based barriers exist which limit the implementation of such models into practice, particularly in rural areas where unique access issues exist. In order to improve health service delivery for consumers with CLBP, policymakers and service providers require a more in depth understanding of these issues. The objective of this qualitative study was to explore barriers experienced by consumers in rural settings in Western Australia (WA) to accessing information and services and implementing effective self-management behaviours for CLBP.MethodsFourteen consumers with a history of CLBP from three rural sites in WA participated. Maximum variation sampling was employed to ensure a range of experiences were captured. An interviewer, blinded to quantitative pain history data, conducted semi-structured telephone interviews using a standardised schedule to explore individuals’ access to information and services for CLBP, and self-management behaviours. Interviews were digitally recorded and transcribed verbatim. Inductive analysis techniques were used to derive and refine key themes.ResultsFive key themes were identified that affected individuals’ experiences of managing CLBP in a rural setting, including: 1) poor access to information and services in rural settings; 2) inadequate knowledge and skills among local practitioners; 3) feelings of isolation and frustration; 4) psychological burden associated with CLBP; and 5) competing lifestyle demands hindering effective self-management for CLBP.ConclusionsConsumers in rural WA experienced difficulties in knowing where to access relevant information for CLBP and expressed frustration with the lack of service delivery options to access interdisciplinary and specialist services for CLBP. Competing lifestyle demands such as work and family commitments were cited as key barriers to adopting regular self-management practices. Consumer expectations for improved health service coordination and a workforce skilled in pain management are relevant to future service planning, particularly in the contexts of workforce capacity, community health services, and enablers to effective service delivery in primary care.

A critical look at the role of self-management for people with arthritis and other chronic diseases

Most patients with chronic conditions, such as osteoarthritis, only have contact with healthcare professionals for a few hours over the course of a year. Good self-management programs are, therefore, critical for patients to cope with their conditions on a daily basis. Drs Osborne, Jordan and Rogers discuss the importance of engaging patients, clinicians and policymakers in the development and implementation of self-management programs.

Supporting evaluation and implementation of musculoskeletal Models of Care: A globally-informed framework for judging 'readiness' and 'success'.

To develop a globally informed framework to evaluate readiness for implementation and success after implementation of musculoskeletal models of care (MOCs).

Young people's experiences of persistent musculoskeletal pain, needs, gaps and perceptions about the role of digital technologies to support their co-care: a qualitative study

Objective To investigate young peoples experiences of persistent musculoskeletal pain, including care needs and current service gaps as well as perceptions about the role of digital technologies to support their co-care. Methods A qualitative study employing two independent data collection modes: in-depth individual semistructured interviews and focus groups. Setting Community settings throughout Australia. Participants Participants were included if they had experienced persistent musculoskeletal pain of >3-month duration with an average of ≥3 on the visual analogue scale over the preceding 3 months, including non-specific conditions (eg, low back pain) and specific conditions (eg, juvenile idiopathic arthritis and other systemic arthritides), with/without pre-existing or current diagnosed mental health conditions. 23 young people (87.0% women; mean (SD) age: 20.8 (2.4) years) from across 6 Australian jurisdictions participated. Almost two-thirds of participants with persistent musculoskeletal pain reported comorbid mental health conditions. Main outcome measures Inductive and deductive approaches to analyse and derive key themes from verbatim transcripts. Results Participants described their daily experiences of living with persistent musculoskeletal pain, their fears and the challenges imposed by the invisibility of pain, and the two-way relationship between their pain and mental well-being. A lack of relevant and accessible information and resources tailored to young peoples unique needs, integrated and youth-relevant healthcare services and adequately skilled healthcare practitioners were identified as key care gaps. Participants strongly advocated for the use of digital technologies to improve access to age-appropriate resources and support for co-care. Conclusions Young people living with persistent musculoskeletal pain described the absence of age-appropriate pain services and clearly articulated their perceptions on the role of, and opportunities provided by, digital technologies to connect with and support improved pain healthcare. Innovative and digitally-enabled models of pain care are likely to be helpful for this group.

The importance of health literacy in physiotherapy practice

Physiotherapy practice is changing rapidly, with greater leadership opportunities and recognition of physiotherapy across healthcare sectors. For example, physiotherapists increasingly hold leadership roles in management of chronic disease and other inter-professional teams, engage in extended scope of practice duties, perform triage roles in tertiary centre clinics and emergency departments, have the opportunity to progress to clinical specialisation, and lead prestigious research programs. Such professional advances bring greater responsibilities in providing health information. Indeed, continued recognition as important and highly skilled health professionals demands that we deliver reliable and accurate health information to our patients and stakeholders so that they can make informed decisions about their healthcare.

Establishing cross-discipline consensus on contraception pregnancy and breast feeding-related educational messages and clinical practices to support women with rheumatoid arthritis: an Australian Delphi study.

Objective Recognising the need for a best-practice and consistent approach in providing care to women with rheumatoid arthritis (RA) in relation to (1) general health, (2) contraception, (3) conception and pregnancy, (4) breast feeding and (5) early parenting, we sought to achieve cross-discipline, clinical consensus on key messages and clinical practice behaviours in these 5 areas. Design 3-round eDelphi study. In round 1, panellists provided free-text responses to open-ended questions about care for women with RA across the 5 areas. Subsequently, panellists refined and scored the synthesised responses, presented as metathemes, themes and detailed elements. Where ≥5% of panellists did not support a theme in a given round, it was removed. Setting Panel of practicing Australian rheumatologists (n=22), obstetricians/obstetric medicine physicians (n=9) and pharmacists (n=5). Results 34 (94.4%) panellists participated in all 3 rounds. The panel supported 18 themes across the 5 areas (support/strongly support: 88.2–100%) underpinned by 5 metathemes. Metathemes focused on coordination in information delivery, the mode and timing of information delivery, evidence underpinning information, engagement of the right health professionals at the right time and a non-judgemental approach to infant feeding. Themes included practices for primary prevention of chronic disease and their sequelae, the importance of contraception and planning pregnancy and breast feeding, close monitoring of medications, supporting mental well-being, managing disease activity and providing practical support for early parenting. Conclusions A cross-disciplinary clinical panel highly supported key information and clinical practices in the care for women with RA across the continuum of contraception to early parenting within a whole-person, chronic disease management approach.