Shoou Yih Daniel Lee

Review: Conceptualization and Measurement of Organizational Readiness for Change A Review of the Literature in Health Services Research and Other Fields

Health care practitioners and change experts contend that organizational readiness for change is a critical precursor to successful change implementation. This article assesses how organizational readiness for change has been defined and measured in health services research and other fields. Analysis of 106 peer-reviewed articles reveals conceptual ambiguities and disagreements in current thinking and writing about organizational readiness for change. Inspection of 43 instruments for measuring organizational readiness for change reveals limited evidence of reliability or validity for most publicly available measures. Several conceptual and methodological issues that need to be addressed to generate knowledge useful for practice are identified and discussed.Health care practitioners and change experts contend that organizational readiness for change is a critical precursor to successful change implementation. This article assesses how organizational readiness for change has been defined and measured in health services research and other fields. Analysis of 106 peer-reviewed articles reveals conceptual ambiguities and disagreements in current thinking and writing about organizational readiness for change. Inspection of 43 instruments for measuring organizational readiness for change reveals limited evidence of reliability or validity for most publicly available measures. Several conceptual and methodological issues that need to be addressed to generate knowledge useful for practice are identified and discussed.

Effects of health literacy on health status and health service utilization amongst the elderly

Amid increased concerns about the adverse consequences of low health literacy, it remains unclear how health literacy affects health status and health service utilization. With a sample of 489 elderly Medicare patients in a Midwestern city in the USA, we explored the intermediate factors that may link health literacy to health status and utilization of health services such as hospitalization and emergency care. We expected to find that individuals with higher health literacy would have better health status and less frequent use of emergency room and hospital services due to (1) greater disease knowledge, (2) healthier behaviors, (3) greater use of preventive care, and (4) a higher degree of compliance with medication. Using path analysis, we found, however, that health literacy had direct effects on health outcomes and that none of these variables of interest was a significant intermediate factor through which health literacy affected use of hospital services. Our findings suggest that improving health literacy may be an effective strategy to improve health status and to reduce the use of expensive hospital and emergency room services among elderly patients.

Organizational Demography and Turnover: An Examination of Multiform and Nonlinear Heterogeneity

This paper advances the study of organizational demography and turnover by testing propositions derived from Blaus theory of heterogeneity and social structure. In a sample of 398 U.S. community hospitals, voluntary nursing turnover was examined in relation to three demographic dimensions-educational preparation, tenure and employment status-among nurse staff. The form of relationships between turnover and heterogeneity was specified to test whether heterogeneity affects turnover in a linear fashion or, alternatively, in an inverted U-shaped pattern. Our results suggest that effects of heterogeneity on turnover differ by dimension and that such effects can obtain independently of other dimensions. Further, interactions between demographic dimensions show that demographic dimensions also interact with each other to affect nursing turnover. Our findings partially support Blaus conceptualization of heterogeneity in social structure and highlight the importance of multiform heterogeneity in the study of organizational demography and group interaction outcomes.

Provision of Community Benefits by Tax-Exempt U.S. Hospitals

BACKGROUND The Patient Protection and Affordable Care Act (ACA) requires tax-exempt hospitals to conduct assessments of community needs and address identified needs. Most tax-exempt hospitals will need to meet this requirement by the end of 2013. METHODS We conducted a national study of the level and pattern of community benefits that tax-exempt hospitals provide. The study comprised more than 1800 tax-exempt hospitals, approximately two thirds of all such institutions. We used reports that hospitals filed with the Internal Revenue Service for fiscal year 2009 that provide expenditures for seven types of community benefits. We combined these reports with other data to examine whether institutional, community, and market characteristics are associated with the provision of community benefits by hospitals. RESULTS Tax-exempt hospitals spent 7.5% of their operating expenses on community benefits during fiscal year 2009. More than 85% of these expenditures were devoted to charity care and other patient care services. Of the remaining community-benefit expenditures, approximately 5% were devoted to community health improvements that hospitals undertook directly. The rest went to education in health professions, research, and contributions to community groups. The level of benefits provided varied widely among the hospitals (hospitals in the top decile devoted approximately 20% of operating expenses to community benefits; hospitals in the bottom decile devoted approximately 1%). This variation was not accounted for by indicators of community need. CONCLUSIONS In 2009, tax-exempt hospitals varied markedly in the level of community benefits provided, with most of their benefit-related expenditures allocated to patient care services. Little was spent on community health improvement.

Short Assessment of Health Literacy—Spanish and English: A Comparable Test of Health Literacy for Spanish and English Speakers

OBJECTIVE The intent of the study was to develop and validate a comparable health literacy test for Spanish-speaking and English-speaking populations. STUDY DESIGN The design of the instrument, named the Short Assessment of Health Literacy-Spanish and English (SAHL-S&E), combined a word recognition test, as appearing in the Rapid Estimate of Adult Literacy in Medicine (REALM), and a comprehension test using multiple-choice questions designed by an expert panel. We used the item response theory (IRT) in developing and validating the instrument. DATA COLLECTION Validation of SAHL-S&E involved testing and comparing the instrument with other health literacy instruments in a sample of 201 Spanish-speaking and 202 English-speaking subjects recruited from the Ambulatory Care Center at the University of North Carolina Healthcare System. PRINCIPAL FINDINGS Based on IRT analysis, 18 items were retained in the comparable test. The Spanish version of the test, SAHL-S, was highly correlated with other Spanish health literacy instruments, Short Assessment of Health Literacy for Spanish-Speaking Adults (r=0.88, p<.05) and the Spanish Test of Functional Health Literacy in Adults (TOFHLA) (r=0.62, p<.05). The English version, SAHL-E, had high correlations with REALM (r=0.94, p<.05) and the English TOFHLA (r=0.68, p<.05). Significant correlations were found between SAHL-S&E and years of schooling in both Spanish- and English-speaking samples (r=0.15 and 0.39, respectively). SAHL-S&E displayed satisfactory reliability of 0.80 and 0.89 in the Spanish- and English-speaking samples, respectively. IRT analysis indicated that the SAHL-S&E score was highly reliable for individuals with a low level of health literacy. CONCLUSIONS The new instrument, SAHL-S&E, has good reliability and validity. It is particularly useful for identifying individuals with low health literacy and could be used to screen for low health literacy among Spanish and English speakers.It is hardly news anymore that a significant proportion of adults in the United States have difficulty navigating the health care system and managing personal health issues because of inadequate health literacy or limited “capacity to obtain, process, and understand health information and services needed to make appropriate health decisions” (Seldon, Zorn, Ratzan, & Parker, 2000). Inadequate health literacy, as a growing body of research has shown, is a risk factor for patients’ difficulties in understand health information and following medical instructions (Cho, Lee, Arozullah, & Crittenden, 2008; Davis et al., 2006; Gazmararian, Williams, Peel, & Baker, 2003; Parker, Ratzan, & Lurie, 2003), poor disease/self-management knowledge (Gazmararian et al., 2003), underuse of preventive services and routine physician and dental visits (Baker et al., 2004; Jones, Lee, & Rozier, 2007; Lindau, Basu, & Leitsch, 2006; Lindau et al., 2002; Rogers, Wallace, & Weiss, 2006; Scott, Gazmararian, Williams, & Baker, 2002), increased hospitalizations and medical costs (Baker et al., 2002; Howard, Gazmararian, & Parker, 2005), and high mortality rates (Sudore et al., 2006). Identifying individuals with inadequate health literacy is difficult because information such as age, educational attainment (i.e., years of schooling), and self-reported literacy skills do not reliably reflect an individual’s health literacy level (Bass, Wilson, Griffith, & Barnett, 2002; Davis, Jackson, George, et al., 1993; Davis, Arnold, Berkel, et al., 1996; Nurss, el-Kebbi, Gallina, et al., 1997). Over the years, several instruments, including the Test of Functional Health Literacy in Adults (TOFHLA), the Rapid Estimate of Adult Literacy in Medicine (REALM), and the Newest Vital Sign (NVS), have been developed to assess health literacy in the U.S. (Davis et al., 1993; Murphy, Davis, Long, Jackson, & Decker, 1993; Parker, Baker, Williams, & Nurss, 1995; Weiss et al., 2005). Most of the instruments, however, have a strong focus on the English-speaking populations and are inappropriate for assessing the health literacy level of Spanish-speakers. In the case of REALM, an attempt to develop a Spanish version failed because of the phonetic structure of the Spanish language (Nurss, Baker, David, Parker, & Williams, 1995).1 Where a Spanish version is available, e.g., TOFHLA-Spanish, the Spanish instrument is usually developed using a rudimentary translation-and-back-translation technique and is not validated psychometrically. A recent study comparing the psychometric properties of the English and Spanish versions of shortened TOFHLA raised a significant concern about their comparability (Aguirre, Ebrahim, & Shea, 2005). Our research team developed an easy-to-use health literacy test, the Short Assessment of Health Literacy for Spanish-speaking Adults (SAHLSA), for Spanish-speakers (Lee, Bender, Ruiz, & Cho, 2006). The SAHLSA contains 50 test items and has good psychometric qualities. It has been adopted in research and clinical practice in the U.S. (Keselman et al., 2007; Rosembla & Tse, 2006) and is being validated for use in Latin American countries (Huaman-Calderon, Quiliano-Terreros, & Vilchez-Roman, 2009). Since the publication of SAHLSA, many users have expressed the need for an English version to allow comparisons of health literacy level between Spanish and English speakers for research and clinical purposes. In this paper, we report our subsequent effort to develop a comparable test for Spanish and English-speakers, named Short Assessment of Health Literacy-Spanish & English or SAHL-S&E, based on the same methods used in developing SAHLSA. The test contains 18 items and is easy to administer. In taking the test, examinees are asked to read aloud each of the 18 medical terms and then associate each term to another word similar in meaning to demonstrate comprehension. The following sections describe the development of the SAHL-S&E, the methods employed to validate the instrument, results of the validation, and recommendations for use of the instrument.

Review: Use of Qualitative Methods in Published Health Services and Management Research: A 10-Year Review

Over the past 10 years, the field of health services and management research has seen renewed interest in the use of qualitative research methods. This article examines the volume and characteristics of qualitative research articles published in nine major health services and management journals between 1998 and 2008. Qualitative research articles comprise 9% of research articles published in these journals. Although the publication rate of qualitative research articles has not kept pace with that of quantitative research articles, citation analysis suggests that qualitative research articles contribute comparably to the field’s knowledge base. A wide range of policy and management topics has been examined using qualitative methods. Case study designs, interviews, and documentary sources were the most frequently used methods. Half of qualitative research articles provided little or no detail about key aspects the study’s methods. Implications are discussed and recommendations are offered for promoting the publication of qualitative research.

Governance forms in health systems and health networks

Debates about the relative advantages of health systems versus more loosely structured health networks have largely ignored issues of how these different organizational forms are governed. Based on comparisons of two large samples of health systems and health networks, our findings indicate that the majority of both types of organized delivery systems have governing bodies separate from those of affiliate organizations, high proportional representation by affiliate organizations, and similar board size.

Health Literacy, Social Support, and Health Status Among Older Adults

The study examines whether social support interacts with health literacy in affecting the health status of older adults. Health literacy is assessed using the short version of the Test of Functional Health Literacy in Adults. Social support is measured with the Medical Outcome Study social support scale. Results show, unexpectedly, that rather than buffering the negative effect of low health literacy, social support has a more positive impact on physical health in older adults with high health literacy. Implications for improving the health status of older adults through health literacy and social support are discussed.

Use of Preventive Maternal and Child Health Services by Latina Women A Review of Published Intervention Studies

Some health indicators for Latinos tend to be more positive than socioeconomic status would predict. Yet, Latina women and their young children use fewer preventive health services and have a higher incidence of preventable diseases than non-Hispanic whites. The Institute of Medicine recently called for intervention research among minority subgroups to end racial and ethnic disparities in health care. To help guide future intervention research, this article presents a critique and synthesis of the peer-reviewed literature on interventions that enroll Latina women into preventive reproductive health services (prenatal care, cervical cancer screening, and child immunizations). Results are presented according to three categories of interventions: improvements within formal health care settings, outreach through lay health advisors (promotoras) and media, and interventions combining these approaches. An agenda for intervention research is proposed for preventive-care use by this population.

Whom do they serve? Community responsiveness among hospitals affiliated with health systems and networks

Background. As the US hospital sector becomes more consolidated, concerns have been raised about whether participation in health systems and health networks may reduce community hospitals’ response to community health needs. Objectives. The following were examined: (1) whether freestanding hospitals and system- and network-affiliated hospitals differed in their level of community responsiveness; and (2) how systems and networks affect the level of community responsiveness in community hospitals. Methods. A cross-sectional design was used. The dependent variables included community orientation, provision of community health services, and Medicaid inpatient load. Independent variables were system/network membership and policy and organizational attributes of the health system/network. Results. With few exceptions, a significantly greater involvement of system and network hospitals was found in providing community health services and inpatient services to Medicaid patients, relative to freestanding hospitals. Community health mission of the system/network and the involvement of the system/network in community partnerships or coalitions were positively related to community orientation in member hospitals. Hospitals affiliated with health systems and hospitals affiliated with more diversified systems or networks tended to provide more community health services. Community health mission of the health system or network was related to greater Medicaid inpatient load in member hospitals. Conclusions. In general, affiliation with health systems and health networks appears to be positively related to community responsiveness in community hospitals. Research future can examine whether such greater community responsiveness is because of the development and improvement of communication channels among elements of health systems and health networks and the ability of health systems and health networks to build a platform of general, administrative services to link various constituencies.