The possibility of patient-centered dietetic intervention in the context of health literacy in Hungary

Low health literacy (HL) adversely affects medical adherence and health outcomes in patients with chronic diseases. However, the association between HL and enhanced recovery after surgery (ERAS) adherence and postoperative outcomes has not been investigated in patients undergoing colorectal surgery. The data of all patients from a single academic institution who underwent colorectal surgery on an ERAS pathway from January 2019 to July 2020 were prospectively collected. HL levels were assessed using the Brief Health Literacy Screen (BHLS), a proven tool that was used by surgeons after recruitment. According to the HL score, the participants were categorized into low HL (≤9 points) and high HL (10-15 points) groups. The primary outcome was ERAS adherence. Adherence was measured in 22 perioperative elements, and high adherence was defined as adherence to 17 to 22 elements. Secondary outcomes included postoperative complications, hospital length of stay (LOS), hospital charges, mortality, and readmissions. Of the 865 eligible patients, the high HL group consisted of 329 patients (38.0%), and the low HL group contained 536 patients (62.0%). After propensity score matching (1:1), 240 unique pairs of patients with similar characteristics were selected. Patients with high HL levels had a significantly higher rate of high adherence to ERAS standards than those with low HL levels (55% vs 25.8%; adjusted P < .001). In terms of adherence to each item, high HL levels were significantly associated with higher adherence to preoperative optimization (90.8% vs 71.7%; adjusted P < .001), postoperative gum chewing (59.2% vs 44.6%; adjusted P = .01), early feeding (59.2% vs 31.3%; adjusted P < .001), and early mobilization (56.7% vs 30.4%; adjusted P < .001). In the overall study population, adjusted logistic regression analyses also showed that high HL levels were associated with a significantly increased rate of high adherence when compared with low HL levels (adjusted odds ratio [OR], 3.57; 95% confidence interval (CI), 2.50-5.09; P < .001). In addition, low HL levels were associated with a significantly higher incidence of postoperative complications (32.1% vs 20.8%; P < .01), longer hospital LOS (9 [interquartile range {IQR}, 7-11] vs 7 [IQR, 6-9] d; P < .001), and higher hospital charges (10,489 [IQR, 8995-11942] vs 8466 [IQR, 7733-9384] dollar; P < .001) among propensity-matched patients. However, there were no differences in the mortality and readmission rates between the HL groups. Low HL levels were associated with lower adherence to ERAS elements among propensity-matched patients undergoing colorectal surgery.

Relationship between communicative and critical health literacy, health information sources, and participation in health checkups among middle-aged Japanese community residents

OVER THE NEXT 3 YEARS, STATE AND LOCAL OFFIcials will be responsible for reaching out to and enrolling more than 30 million individuals in publicly funded or subsidized health plans offered through state insurance exchanges. Because low health literacy tends to be more prevalent in certain minority groups and among those with low income and education, the majority of the newly eligible individuals are likely to have low health literacy. Failure to meet enrollment goals will not only undermine the credibility and success of the Patient Protection and Affordable Care Act (ACA) but, more importantly, will do little to expand health insurance coverage and improve access to care among those at greatest need. Health literacy is “the degree to which individuals have the capacity to obtain, process, communicate, and understand basic health information and services needed to make appropriate health decisions.” A 2004 Institute of Medicine report estimated that 90 million Americans lack the skills needed to understand and act on health information and concluded that “ . . . efforts to improve quality, reduce costs, and reduce disparities cannot succeed without simultaneous improvements in health literacy.” Recent estimates suggest that more than half (53%) of currently uninsured adults—those who will become newly insured under the ACA—have “below basic” or “basic” literacy skills. Such individuals have difficulty with tasks such as finding the date of a physician’s visit on an appointment slip or explaining why someone should have a medical test using information from a clearly written pamphlet. Individuals with low health literacy are less likely to actively participate in health care decision making and more likely to struggle with health management tasks and to face significant challenges navigating the health system. Recent studies also document higher rates of mortality among patients with limited health literacy. This growing evidence base prompted the Institute of Medicine to select “improving the health literacy of the population” as one of 24 Healthy People 2020 objectives submitted to the Department of Health and Human Services to help guide the US health agenda. The ongoing evolution of the health care system is leading US households toward greater responsibility for their own well-being. With this responsibility, however, comes an increasing need to be able to find, trust, use, and act on relevant information to make informed choices. Yet there continues to be a substantial mismatch between the high literacy burden of health information materials designed to support such choices and the health and financial literacy skills of individuals who use them. For example, approximately 9 of 10 US adults (88%) cannot calculate an employee’s share of health insurance costs using a table based on income and family size. In the current economic and policy environment, low health and financial literacy remains a barrier to reducing gaps in health care, raising concerns about the health and well-being of those who are unprepared for the increasing responsibility of choice. Enrollment in a health insurance plan, particularly a government-funded or subsidized plan in which eligibility must be verified, is a complex task. Individuals must navigate the system to find accurate and usable information; understand eligibility guidelines, complete forms, and provide mandatory citizenship and financial documentation necessary for enrollment (and for periodic reestablishment of eligibility); understand concepts such as premiums, copayments, and benefits and be able to apply these concepts to their existing or anticipated health situation to select the most appropriate plan; understand which services are and are not covered; and complete additional paperwork to enroll in their selected plan. The steps must occur prior to an actual visit with their physician, during which patients may spend limited time obtaining the information that is essential for maintaining optimal health and managing acute and chronic health conditions. In addition to developing a consumer-friendly enrollment system, evidence from Massachusetts’ 2006 reforms suggest that financially supporting community-based organizations and health care practitioners to help consumers navigate the process and fill out applications is effective: of all successful subsidy applications, 60% were completed with personal assistance to the consumers by such organizations.

OR7. Health Literacy and the Inpatient Nurse: Defining Core Competencies at an Academic Medical Center

Introduction: Patients with low health literacy (HL) and minority patients encounter many challenges during transition from hospital to community care. We aimed to assess care transitions of patients from minority Arab and immigrant population groups and various HL levels and to test whether presence of caregivers and provision of language-concordant care are associated with better transitions. Methods: This prospective cohort study included 598 internal medicine patients, Hebrew, Russian, or Arabic native speakers, at a tertiary medical center in central Israel, from 2013 to 2014. Baseline measures included: HL (Brief Health Literacy Screen); mental and physical health status (SF-12v.2); daily functioning. A follow-up telephone survey assessed patients’ care transitions (Care Transition Measure [CTM]). Additionally, patients reported on care provisions at discharge: caregiver presence (family members/ close relations) and patient-provider language concordance. Results: Caregivers were present in 59% (351/598) of discharge briefings and patient-provider language concordance was available in 30% (123/408) of minority patients' discharge briefings. Patients with low HL and without language-concordance or caregiver presence had the lowest CTM scores (33.1). When language-concordance and caregivers were available, CTM scores did not differ between the medium-high and low HL groups (72.30 and 68.40, respectively, p=0.118). The adjusted analysis with tests of interaction, showed that language-concordance and caregiver presence during discharge moderate the relationship between HL and patients' care transition experience (p Discussions: This study examined the relationship between HL and patients’ transitional-care experience. Collectively, our data underscore two important points: (1) HL is inversely associated with patients’ ratings of their care transitions, and (2) provisions of care during discharge moderate the relationship between HL and patients' care transition experience. These findings show that the negative impact of low HL is potentially mitigated when language-concordance and caregiver presence are available during discharge. Moreover, our findings on the independent effect of caregiver presence and language-concordance, at both low and medium-high HL levels, show that transitional care of all patients is better when these provisions are available. Nonetheless, for patients with low HL, absence of caregivers and lack of language-concordance is detrimental for their transitional care. Conclusions: This study shows that language-concordance care and caregiver presence are associated with better patients’ transitional-care experience among patients with low HL levels and among minorities in general Lessons learned: Our findings point to a need to identify patients at risk for poor understanding and execution of hospital discharge instructions. This entails determining patients’ HL levels and ensuring that discharge briefings are given by language-concordant providers and when caregivers are present. Limitations: The findings reflect cultural and healthcare characteristics of the Israeli society, which might not be applicable to other countries. However, studies from various developed countries show that deficits in communication at hospital discharge are a common problem that may adversely affect patient care. Suggestions for future research: Future studies should explore how these provisions may lead to improved health outcomes and reductions in hospital readmissions.

It is often recommended that health information should be simplified for people with low health literacy. However, little is known about whether messages adapted to low health literacy audiences are also effective for people with high health literacy, or whether simple messages are counterproductive in this group. Using a two (illustrated vs. text-only) by two (nondifficult vs. difficult text) between-subjects design, we test whether older adults with low (n = 279) versus high health literacy (n = 280) respond differently to colorectal cancer screening messages. Results showed that both health literacy groups recalled information best when the text was nondifficult. Reduced text difficulty did not lead to negative attitudes or less intention to have screening among people with high health literacy. Benefits of illustrations, in terms of improved recall and attitudes, were only found in people with low health literacy who were exposed to difficult texts. This was not found for people with high health literacy. In terms of informed decisions, nondifficult and illustrated messages resulted in the best informed decisions in the low health literacy group, whereas the high health literacy group benefited from nondifficult text in general, regardless of illustrations. Our findings imply that materials adapted to lower health literacy groups can also be used for a more general audience, as they do not deter people with high health literacy.

This paper reports a pilot project at Harvard Medical School (HMS) that taught medical students the importance of plain language communication by collaborating with adult literacy students. Classes provided students with patient-doctor communication experience and health information. After a lecture on health literacy and cross-cultural care, a librarian taught students where to find high-quality, easy-to-read, and non-English health information. Adult learners identified health topics of interest. Medical students then created presentations on these topics and received critical feedback from the adult students. HMS students improved their use of plain language communication and their understanding of health disparities. Everyone expressed a desire to learn more. The project demonstrated that health literacy competencies can be integrated into medical school instruction using a combination of didactic and experiential methods. Medical schools and their librarians are in a unique position to work with future providers to ameliorate the problem of low health literacy. The profound consequences of poor health literacy have been well documented and indicate that vast amounts of health information are incomprehensible to millions of people [1–4]. People with low functional health literacy have more difficulty navigating the health care system and obtaining services. They are less likely to comprehend the written and oral information given to them by providers. They are also more likely to suffer higher health care costs and disproportionately have poorer health outcomes than those with high levels of health literacy. Older people, nonwhites, immigrants, and low-income people constitute a large segment of people with low health literacy [3]. Issues of culture, language, and learning are interrelated, and to be effective, health information must be provided in both culturally and linguistically appropriate formats to address the increasingly diverse multicultural and multilingual population [4]. The Liaison Committee on Medical Education of the American Association of Medical Colleges (AAMC), the American Medical Association (AMA), and the Institute of Medicine (IOM) all emphasize the need to address these issues in medical education [5–8]. While other medical education efforts focused on health literacy are described in the literature, their methodology relies on role-playing between medical students and faculty [8,9]. To the authors' knowledge, this class was different because it offered an opportunity to work with adult literacy students. The creation and implementation of this educational opportunity by the coauthors, a community service program manager and a librarian, illustrates a novel pathway for medical librarians to share their knowledge of health literacy with both adult learners and medical students. Medical librarians are active in the health literacy movement, participating as both consumer health information specialists and educators for health care professionals. The Medical Library Association's Health Information Literacy (HIL) web page—with links to projects, presentations, and information sources created by librarians—provides evidence of this involvement [10]. The Countway Library at HMS has hosted displays to raise awareness of health literacy issues both at the library and in the medical education building.

Objective To explore the influences of health literacy level on psychological problems and help-seeking willingness and attitudes in adolescents. Methods The study investigated 1 070 adolescents using convenience sampling. The health literacy scale, help-seeking willingness and attitudes questionnaire were used to evaluate the impacts of health literacy level on psychological problems and help-seeking willingness, attitudes. Results The scores of psychological problems, anxiety/depression, physical discomfort, ideological problems, attention problems, negligence and withdrawal behavior were lower in high health literacy group than in low health literacy group (P<0.05). Logistical regression analysis demonstrated that the higher health literacy level was the protective factor for psychological problems (OR=0.570) and the scores of the help-seeking willingness and attitudes were higher in high health literacy group than in low health literacy group (P<0.05). Pearson correlation analysis showed that the total score of health literacy were positively correlated with the scores of help-seeking willingness and attitudes (P<0.05). Conclusions The higher level of health literacy indicates the higher help-seeking willingness and attitudes, which is benefit to prevent psychological problems. Key words: Adolescent; Psychological processes; Attitude; Health literacy; Behavior problems

BackgroundChronic disease is the leading global health threat and impairs patients’ health-related quality of life (HRQoL). Low health literacy is linked with chronic diseases prevalence and poor HRQoL. However, the interaction of health literacy with chronic disease on HRQoL remains unknown. Therefore, we examined how health literacy might modify the association between chronic disease and their HRQoL impacts.MethodsWe conducted a health survey of 913 poor rural women aged 23–57 years in Northwestern China. We assessed health literacy and HRQol using the revised Chinese Adult Health Literacy Questionnaire (R-CAHLQ) and Euroqol-5D (EQ-5D), respectively. Low health literacy was indicated by a cut-off of less than the mean of the factor score. Self-reported preexisting physician-diagnosed chronic disease and socio-demographic characteristics were also included. We fitted log-binomial regression models for each dimension of EQ-5D to examine its association with health literacy and chronic disease. We also ran linear regression models for EQ VAS scores and utility scores.ResultsThe low health literacy group was 1.33 times more likely to have a chronic disease than the high health literacy group. Pain/discomfort was the most prevalent impairment, and was more common in the low health literacy group (PR [prevalence ratio] = 1.23; 95% CI = 1.01, 1.50). Chronic disease strongly predicted impairments in all the EQ-5D dimensions, with PRs ranging from 2.14 to 4.07. The association between chronic disease and pain/discomfort varied by health literacy level (health literacy × chronic disease: P = 0.033), and was less pronounced in the low health literacy group (PR = 2.15; 95% CI = 1.76, 2.64) than in the high health literacy group (PR = 3.19; 95% CI = 2.52, 4.05). The low health literacy group had lower VAS scores and utility scores, and slightly less decrement of VAS scores and utility scores associated with chronic disease.ConclusionsHealth literacy modified the impacts of chronic disease on HRQoL, and low health literacy group reported less HRQoL impacts related to chronic disease. Research should address health literacy issues as well as root causes of health disparities for vulnerable populations.

207 Background: Preoperative education is an important component of surgical cancer care that has been shown to impact surgical outcomes. However, the quality of education varies, especially among patients with low health literacy (HL), which is prevalent among states in the Deep South. Low HL patients experience worse surgical outcomes, and variation in preoperative education further increases the disparity gap for this vulnerable patient population. We aimed to characterize patient perspectives of preoperative education by HL level among gastrointestinal cancer patients in the Deep South. Methods: Surveys were administered to colorectal, pancreatic, and esophageal cancer survivors in Alabama and Mississippi. Eligible participants had stage 1-3 cancer, were within 5 years of diagnosis, and had surgery as part of their cancer care. Participants were also administered the BRIEF survey, which is a validated four question survey measuring HL level. Patients with a score of 17 or higher were categorized as having adequate HL, while a score of 16 or less were categorized as having low HL. Fisher Exact or Chi Square tests were performed to examine significant differences between patients with low and adequate HL. Results: Of 272 survey respondents, the mean age was 63.17 (±11.57) and 151 (55.5%) were women. 92 (33.8%) had low HL and 174 (64.0%) had adequate HL. Compared to patients with adequate HL, patients with low HL reported lower rates of a health care provider in the surgeon’s clinic definitely giving them all the information needed about their surgery (80.9% versus 90.1%, p=0.07) and lower rates of their surgeon or other provider definitely talking to them about what to expect for surgery and recovery (76.4% versus 89.0%, p=0.03, respectively). Low and adequate HL patients reported similar rates of receiving instructions about getting ready for surgery (88.6% and 90.1%, p=0.66). However, 88.3% of low HL patients reported these instructions were easy to understand compared to 97.4% for adequate HL patients (p=0.001). Low and adequate HL patients reported similar rates of visual aids used during education (76.1% versus 78.2%, p=0.54, respectively), with low HL patients reporting slightly lower use of flyers/pamphlets with pictures (58.7% versus 60.3%, p=0.79) and drawings (40.2% versus 42.5%, p=0.72); similar use of models (9.8% versus 9.2%, p=0.86); and less frequent use of videos (7.6% versus 10.9%, p=0.39). Conclusions: Patient-reported disparities in preoperative education exist among surgical cancer patients with low health literacy. 1 in 5 patients with low HL did not think they received enough information prior to surgery and the information they received was difficult to understand. Overall, there was a low use of visual aids among this patient population. Future directions should aim to improve the quality of education for low HL, incorporating the use of visual aids.

Background: Low or limited health literacy is a significant problem in the United States as one in three adults in the United States has inadequate health literacy. Low or limited health literacy contributes to poorer health outcomes for patients and increases costs to the consumer and health care system. Strategies that health care professionals can utilize to overcome these barriers include Health Literacy Universal Precautions, Teach Back, and using simple language. Objective: Standardized health literacy training was inconsistent for community health workers (CHWs) resulting in CHWs having difficulty communicating health-related information to the vulnerable populations they serve who often have low to limited health literacy. A contributing factor is the lack of standardized health literacy training, for nonlicensed health care workers. The aim of this study was to evaluate the CHWs' knowledge about health literacy and self-efficacy after targeted health literacy training. Methods: A pre-test, teaching intervention, and posttest were administered by the principal investigator using the Health Literacy Knowledge and Experience Survey (HLKES-2) to measure the CHW's knowledge and self-efficacy by comparing pre- and postdata results. Five virtual 2.5-hour targeted health literacy training courses were conducted by the primary investigator over a 4-month period. The participants (n = 50) were a sample of CHWs across several regions of the state of Pennsylvania. Results: There was a statistically significant difference between both the pre- and posttest scores of the HLKES-2 after the training (p < 0.0001) in the CHW's health literacy knowledge and a statistically significant change (p < 0.03) in their self-efficacy. Demographics revealed statistically significant changes (p < 0.003) that the higher the education (i.e., secondary education or higher) the better the scores on the HLKES-2 survey. Conclusions: Confident, knowledgeable health care workers can enhance health outcomes for patients with low health literacy in many settings. The combined use of education and technology within standardized, targeted health literacy training can promote support of CHWs. Implications for Nursing: Nursing holds a key role in supporting the education of CHWs. This quality improvement study showed a positive correlation between the targeted health literacy training participation and higher knowledge levels and self-efficacy of the CHWs.

Objective:Although health problems are often a natural consequence of aging, many older adults struggle to manage their health care problems. Health literacy refers to the ability to access, process, and use health information to make appropriate decisions to promote good overall health. Low levels of health literacy are associated with a host of negative outcomes such as less efficient use of healthcare services, higher healthcare costs, increased mortality, and poorer self-rated health. In those with medical conditions (e.g., diabetes), lower health literacy is linked with higher levels of depression. It is important to investigate whether mental health is linked to health literacy as understanding these links has the potential to identify those at risk for negative outcomes and thus implement protective strategies. Therefore, the current study sought to determine the extent to which various mental health constructs such as happiness, well-being, anxiety and depression are related to health literacy in a community-based sample of cognitively healthy individuals. We hypothesized that higher levels of health literacy would be associated with higher self-reported well-being, happiness, and lower anxiety and depression.Participants and Methods:Design - Cross-sectional, prospective study. Setting - Community-based. 93 individuals were included with mean age=59.02 years (SD=15.12) and mean education=15.70 (SD=2.39). 60% were women, the majority were White (55%) while 38% were Black and 7% belonged to other races; 90% were non-Hispanic.Measures:Health Literacy - Health literacy was measured by an 8-item instrument in the Rush Memory and Aging Project that examined the participant’s understanding of health care, treatment, and related behaviors. Happiness - Happiness was measured by 5 items from the Satisfaction with Life Scale using a 7-point scale (1 = strongly agree; 7 = strongly disagree). Higher scores indicated lower levels of happiness. Well-being - Well-being was measured with an 18-item instrument from the Rush Memory and Aging project, with higher scores indicating better well-being. Statistics: Bivariate correlations between age, education, and mental health measures and health literacy were examined.Results:Higher level of health literacy was significantly associated with age (r = .282 p = .009) and education (r = .228 p = .039). Contrary to our hypothesis, health literacy was not significantly associated with happiness (r = .002 p = .987), well-being (r = .037 p = .742), depression (r = .005 p = .962) or anxiety (r = -.064 p = .568). Even after controlling for age and education, these associations remained significant.Conclusions:Higher level of healthy literacy was associated with older age and higher level of education. However, no significant association was found between health literacy and mental health measures of happiness, well-being, depression, and anxiety in cognitively healthy individuals, even after controlling for demographics. The lack of such associations in this study was unexpected and suggests that other factors such as the presence of health conditions (e.g., diabetes, cancer) might critically contribute to such associations. Future studies should examine these associations in a larger context to better understand how to promote healthy self-care behaviors.

Limited health literacy (HL) is associated with a lower medication adherence in patients with chronic obstructive pulmonary disease (COPD). In this study, we examined the potential mitigating role of caregiver support on the relationship between HL and adherence to COPD medications. We conducted a prospective observational study of adults with COPD and their caregivers. HL was assessed using the Short Test of Functional Health Literacy in Adults (S-TOFHLA) and COPD medication adherence was evaluated with the Medication Adherence Rating Scale (MARS). We also collected caregiver HL data for a subset of participants. We tested whether having a caregiver impacted the relationship between HL and medication adherence using cross-sectional data collected between 2011 and 2015. Our sample included 388 COPD patients and 97 caregivers. COPD patients with low HL had a lower medication adherence (odds ratio [OR]: 0.44, 95% confidence interval [CI]: 0.24–0.81) after adjusting for sociodemographic factors. Caregiver presence was not associated with increased patient medication adherence (OR: 1.28, 95% CI: 0.79–2.08). Among the subset of patients with caregivers, low patient HL remained associated with a lower medication adherence (OR: 0.28, 95% CI: 0.09–0.82) when adjusted for caregiver HL and sociodemographic factors. Low HL is associated with lower COPD medication adherence, and this effect is not mitigated by the presence of a caregiver. These findings suggest a need for effective strategies to manage high-risk COPD patients with low HL, even among those with adequate support from caregivers, and to design interventions for both patients and caregivers with low HL.

Health Illiteracy Challenges Long-Term Care

Health literacy: An opportunity for nurses to lead by example