Robert Michielutte

Practical Assessment of Adult Literacy in Health Care

Low literacy is a pervasive and underrecognized problem in health care. Approximately 21% of American adults are functionally illiterate, and another 27% have marginal literacy skills. Such patients may have difficulty reading and understanding discharge instructions, medication labels, patient education materials, consent forms, or health surveys. Properly assessing the literacy level of individual patients or groups may avoid problems in clinical care and research. This article reviews the use of literacy assessments, discusses their application in a variety of health care settings, and cites issues providers need to consider before testing. The authors describe informal and formal methods of screening for reading and comprehension in English and Spanish including the Rapid Estimate of Adult Literacy in Medicine, the Wide Range Achievement Test-3, the Cloze procedure, the Test of Functional Health Literacy in Adults, and others. Practical implications and recommendations for specific use are made.

The Prevalence of Domestic Violence Among Women Seeking Abortion

Objective To determine the prevalence of self-reported abuse in a population of women aged 18 years or older seeking elective pregnancy termination, and to compare abused and nonabused women with respect to the primary reasons for pregnancy termination. Methods A self-administered questionnaire was returned by 486 women seeking outpatient abortion. The survey included demographic information, abuse screening, and items regarding partner involvement/awareness of the pregnancy, and abuse as a determinant of the abortion decision. One open-ended item asking the primary reason for pregnancy termination was included. Results The prevalence of self-reported abuse in this population was 39.5%. White women were significantly more likely to report any history of abuse than nonwhite women. Relationship issues were the only reason for pregnancy termination given more often by women with an abuse history than by nonabused women. Women with abuse histories were significantly less likely than nonabused women to inform the partner of the pregnancy or to have partner support for or involvement in the abortion decision. Conclusion The prevalence of abuse reported by women in this population suggests that many women seeking abortion services may have abuse histories. Abused women may have different reasons for pregnancy termination than nonabused women and may be more likely to make the abortion decision without partner involvement. When routine screening for abuse is included in abortion counseling, health providers have the opportunity for developing a safety plan and initiating appropriate referral.

Factors associated with preterm birth in Cardiff, Wales: II. Indicated and spontaneous preterm birth

OBJECTIVE Our purpose was to examine and contrast associations of risk factors with spontaneous preterm birth and indicated preterm birth. STUDY DESIGN Separate multiple logistic regression analyses were performed of indicated and spontaneous preterm births in a large database of births in Cardiff, Wales. RESULTS Spontaneous preterm births were associated with young maternal age, low maternal weight, low or high parity, previous abortion, smoking, and early pregnancy bleeding. Indicated preterm births were associated with older age, low weight, previous stillbirth, bacteriuria, and early pregnancy bleeding. CONCLUSION Spontaneous and indicated preterm births have different overall profiles of association with pregnancy risk factors.

Factors associated with preterm birth in Cardiff, Wales: I. Univariable and multivariable analysis

OBJECTIVE Our purpose was to examine the associations of demographic, social, and medical factors with risk of preterm birth. STUDY DESIGN By use of the Cardiff Births Survey, a large database of largely homogeneous (white) births in Wales, multivariable analysis by logistic regression examined the relative importance of risk variables associated with preterm birth. RESULTS Significant independent associations with preterm birth were found (in decreasing order of magnitude) for late pregnancy bleeding, preeclampsia-proteinuria, low maternal weight, low maternal age, early pregnancy bleeding, history of previous stillbirth, smoking, high parity, low or high hemoglobin concentration, history of previous abortion, low social class, bacteriuria, and nulliparity. CONCLUSION In this population demographic, social, and medical characteristics of the pregnancies showed significant associations with preterm birth.

The use of illustrations and narrative text style to improve readability of a health education brochure.

Research suggests that much of the available health education literature requires a level of reading ability that makes it inaccessible to a large proportion of the population in greatest need of health information. The present study tested the value of illustrations and a narrative text style as means of improving the readability of a brochure designed to provide information on cervical cancer and condyloma. Two versions of the brochure were designed, one that had only text presented as simple sentences in bullet-type format (SMOG reading level score of 7.7), and a second version that had somewhat more difficult text formatted in a narrative style (SMOG grade level score of 8.4) together with drawings designed to complement the text. A randomized study design was used to test for comprehension, perceived ease of understanding, and overall rating of the two brochures. Women selected from one private and three public health primary-care clinics were randomly assigned to read one of the two brochures. The brochure with illustrations and narrative text was given a significantly higher overall rating than the one with bullet-type text and no illustrations, while no difference was found in perceived ease of reading. Among poor readers, comprehension was significantly greater for women who read the brochure with illustrations and narrative text, with no difference in comprehension of the two brochures for better readers. The results suggest that the use of aids such as illustrations and text style can make health education literature more accessible to high-risk populations, while remaining interesting enough to appeal to individuals at all levels of reading ability.

Racial differences in knowledge, attitudes, and cancer Screening practices among a triracial rural population

Low‐income, minority, and rural women face a greater burden with regard to cancer‐related morbidity and mortality and are usually underrepresented in cancer control research. The Robeson County Outreach, Screening and Education Project sought to increase mammography use among low‐income, minority, and rural women age > 40 years. The current article reports on racial disparities and barriers to screening, especially those related to knowledge, attitudes, and behaviors.

Written informed consent in patients with breast cancer

One hundred breast cancer patients, 35 adjuvant and 65 advanced, were interviewed 0–24 months after the start of chemotherapy to assess their knowledge and perceptions of the purposes, risks and benefits of treatment. Prior to therapy, all had been given verbal explanations and had signed informed consent forms explicitly detailing drugs, objectives and possible adverse effects of therapy. Seventeen percent of adjuvant and 29% of advanced patients were unable to name any of their drugs. While most patients recognized distressing side effects such as nausea and hair loss, less than 50% were aware of the potentially lethal complications of infection and bleeding. While the purpose of adjuvant therapy was cure, only 29% of the adjuvant patients were aware of this. In contrast, 35% of the advanced patients incorrectly stated that they were told their therapy was potentially curative. Explanations given by a nurse in addition to a physician were better understood than those given by a physician alone. We conclude that, in spite of intensive efforts at improving informed consent procedures, current results are unsatisfactory.

An Analysis of Empathy in Medical Students Before and Following Clinical Experience.

The nature and direction of changes in empathy as measured by Hogans empathy scale was explored over time (1975, 1976, and 1979) for medical students in the class of 1979 at the Bowman Gray School of Medicine. Results indicated that empathy scores declined slightly over time, correlated negatively with Medical College Admission Test scores, and were unrelated to academic performance or performance on Part I or Part II examinations of the National Board of Medical Examiners.

Noncompliance in screening follow-up among family planning clinic patients with cervical dysplasia.

This investigation estimated the extent of noncompliance with follow-up to screening for cervical dysplasia at a public health family planning clinic. Available data also permitted examination of the relationship between selected background characteristics and compliance with follow-up. Noncompliance was defined as failure to respond to notification of an abnormal cervical smear (Class III, IV, or V) by failing either to make a follow-up appointment or to keep such an appointment after it was made. The sample consisted of 177 women with abnormal cervical smears who were screened at the Forsyth County Family Planning Clinic between January 1, 1980, and June 30, 1981. Information on the womens compliance with the request for follow-up was obtained from a file specifically kept for this purpose by the clinic nurse. Background characteristics were obtained by reviewing clinic records. Results indicated that approximately 17% of the sample was noncompliant. Noncompliant patients were more likely to be unmarried, less educated, younger, and to have fewer total health problems than women who returned for follow-up. Logistic regression analysis revealed that the number of health problems and educational attainment were the most important predictors of noncompliance.

Racial differences in knowledge of cancer: A pilot study

The present study examined the reported sources of information on cancer and the level of cancer knowledge for a sample of black and white adults. Black respondents had significantly less knowledge and the relationship between race and cancer knowledge persisted even when controlling for education, sex, and age. Possible reasons for the observed difference include (a) the tendency for blacks to obtain information on cancer from television and radio, while whites rely more on printed materials, (b) differences in the quality of education received by black and white adults, and (c) a possible lack of motivation on the part of black respondents to acquire knowledge of cancer due to lower access to medical care. Intervention programs designed to provide all blacks with information about cancer should take into account the preferred sources of information, and should be oriented toward reducing the barriers to taking action related to prevention and early detection as well as increasing perceptions of the benefits of taking such action.