Low-literacy Populations Research Articles

Development of an Ecological Momentary Assessment Mobile App for a Low-Literacy, Mexican American Population to Collect Disordered Eating Behaviors.

BackgroundEcological momentary assessment (EMA) is a popular method for understanding population health in which participants report their experiences while in naturally occurring contexts in order to increase the reliability and ecological validity of the collected data (as compared to retrospective recall). EMA studies, however, have relied primarily on text-based questionnaires, effectively eliminating low-literacy populations from the samples.ObjectiveTo provide a case study of design of an EMA mobile app for a low-literacy population. In particular, we present the design process and final design of an EMA mobile app for low literate, Mexican American women to record unhealthy eating and weight control behaviors (UEWCBs).MethodsAn iterative, user-centered design process was employed to develop the mobile app. An existing EMA protocol to measure UEWCBs in college-enrolled Mexican American women was used as the starting point for the application. The app utilizes an icon interface, with optional audio prompts, that is culturally sensitive and usable by a low-literacy population. A total of 41 women participated over the course of 4 phases of the design process, which included 2 interview and task-based phases (n=8, n=11), focus groups (n=15), and a 5-day, in situ deployment (n=7).ResultsParticipants’ mental models of UEWCBs differed substantially from prevailing definitions found in the literature, prompting a major reorganization of the app interface. Differences in health literacy and numeracy were better identified with the Newest Vital Sign tool, as compared with the Short Assessment of Health Literacy tool. Participants had difficulty imagining scenarios in the interviews to practice recording a specific UEWCB; instead, usability was best tested in situ. Participants were able to use the EMA mobile app over the course of 5 days to record UEWCBs.ConclusionsResults suggest that the iterative, user-centered design process was essential for designing the app to be made usable by the target population. Simply taking the protocol designed for a higher-literacy population and replacing words with icons and/or audio would have been unsuccessful with this population.

Culturally Competent Informed-Consent Process to Evaluate a Social Policy for Older Persons With Low Literacy: The Mexican Case.

The informed-consent process seeks to provide complete information to participants about a research project and to protect personal information they may disclose. In this article, we present an informed-consent process that we piloted and improved to obtain consent from older adults in Yucatan, Mexico. Respondents had limited fluency in Spanish, spoke the local Mayan language, and had some physical limitations due to their age. We describe how we adapted the informed-consent process to comply with U.S. and Mexican regulations, while simplifying the forms and providing them in Spanish and Mayan. We present the challenges and lessons learned when dealing with low-literacy older populations, some with diminished autonomy, in a bilingual context and a binational approach to the legal framework.

Designing Online Nutrition Education for Low Digital Literacy Populations: Insights From the EatFresh.org Mini Course

ObjectiveTo design a user-friendly, evidence-based online nutrition course and accompanying learning management system (LMS) for the SNAP population, many of whom have low digital literacy.Target AudienceAdult (16+), low-income, English and Spanish-speaking participants.Theory, Prior Research, RationaleThis course grew out of EatFresh.org, a recipe and nutrition website. Google Analytics and enthusiasm from partners validated the appropriateness of the website, though an impact evaluation was unable to demonstrate a dose/response relationship in knowledge, attitudes, and behaviors. This course added the capability to assess change on nutrition indicators.DescriptionCourse was developed in leading eLearning software with content management. A combination of in-house staff combined with outsourced engineering created 15 modules and evaluation tools, which were organized into three courses. Staff and contract engineers customized an open-source LMS to build the course. Our design process allowed us to iterate on the instructional strategies, content, and online course structure to create a usable product ready to scale.EvaluationUsing a Reach Effectiveness Adoption Implementation Maintenance (RE-AIM) framework, we focused on Adoption, Implementation and Maintenance as part of our evaluation. A survey of Eatfresh.org partners validated the existence of a vibrant ecosystem for dissemination. Agile design ensured the intervention could be delivered as intended. Software was chosen for content maintenance and sustainability.Conclusions and ImplicationsThe instructional strategies underwent considerable revisions during the first stage of testing leading to the adoption of an engaging narrative structure. Dedicating time to design a simple sign-in and streamlined user flow allowed the focus to be on the dynamic content, as opposed to the mechanics of taking the course.FundingSupplemental Nutrition Assistance Program - Education ObjectiveTo design a user-friendly, evidence-based online nutrition course and accompanying learning management system (LMS) for the SNAP population, many of whom have low digital literacy. To design a user-friendly, evidence-based online nutrition course and accompanying learning management system (LMS) for the SNAP population, many of whom have low digital literacy. Target AudienceAdult (16+), low-income, English and Spanish-speaking participants. Adult (16+), low-income, English and Spanish-speaking participants. Theory, Prior Research, RationaleThis course grew out of EatFresh.org, a recipe and nutrition website. Google Analytics and enthusiasm from partners validated the appropriateness of the website, though an impact evaluation was unable to demonstrate a dose/response relationship in knowledge, attitudes, and behaviors. This course added the capability to assess change on nutrition indicators. This course grew out of EatFresh.org, a recipe and nutrition website. Google Analytics and enthusiasm from partners validated the appropriateness of the website, though an impact evaluation was unable to demonstrate a dose/response relationship in knowledge, attitudes, and behaviors. This course added the capability to assess change on nutrition indicators. DescriptionCourse was developed in leading eLearning software with content management. A combination of in-house staff combined with outsourced engineering created 15 modules and evaluation tools, which were organized into three courses. Staff and contract engineers customized an open-source LMS to build the course. Our design process allowed us to iterate on the instructional strategies, content, and online course structure to create a usable product ready to scale. Course was developed in leading eLearning software with content management. A combination of in-house staff combined with outsourced engineering created 15 modules and evaluation tools, which were organized into three courses. Staff and contract engineers customized an open-source LMS to build the course. Our design process allowed us to iterate on the instructional strategies, content, and online course structure to create a usable product ready to scale. EvaluationUsing a Reach Effectiveness Adoption Implementation Maintenance (RE-AIM) framework, we focused on Adoption, Implementation and Maintenance as part of our evaluation. A survey of Eatfresh.org partners validated the existence of a vibrant ecosystem for dissemination. Agile design ensured the intervention could be delivered as intended. Software was chosen for content maintenance and sustainability. Using a Reach Effectiveness Adoption Implementation Maintenance (RE-AIM) framework, we focused on Adoption, Implementation and Maintenance as part of our evaluation. A survey of Eatfresh.org partners validated the existence of a vibrant ecosystem for dissemination. Agile design ensured the intervention could be delivered as intended. Software was chosen for content maintenance and sustainability. Conclusions and ImplicationsThe instructional strategies underwent considerable revisions during the first stage of testing leading to the adoption of an engaging narrative structure. Dedicating time to design a simple sign-in and streamlined user flow allowed the focus to be on the dynamic content, as opposed to the mechanics of taking the course. The instructional strategies underwent considerable revisions during the first stage of testing leading to the adoption of an engaging narrative structure. Dedicating time to design a simple sign-in and streamlined user flow allowed the focus to be on the dynamic content, as opposed to the mechanics of taking the course.

Adaptation and Latent Structure of the Swahili Version of Beck Depression Inventory-II in a Low Literacy Population in the Context of HIV

ObjectiveWe set out to adapt the Beck Depression Inventory (BDI)-II in Kenya and examine its factorial structure.MethodsIn the first phase we carried out in-depth interviews involving 29 adult members of the community to elicit their understanding of depression and identify aspects of the BDI-II that required adaptation. In the second phase, a modified version of BDI-II was administered to 221 adults randomly selected from the community to allow for the evaluation of its psychometric properties. In the third phase of the study we evaluated the discriminative validity of BDI-11 by comparing a randomly chosen community sample (n = 29) with caregivers of adolescents affected by HIV (n = 77).ResultsA considerable overlap between the BDI symptoms and those generated in the interviews was observed. Relevant idioms and symptoms such as ‘thinking too much’ and ‘Kuchoka moyo (having a tired heart)’ were identified. The administration of the BDI had to be modified to make it suitable for the low literacy levels of our participants. Fit indices for several models (one factorial, two-factor model and a three factor model) were all within acceptable range. Evidence indicated that while multidimensional models could be fitted, the strong correlations between the factors implied that a single factor model may be the best suited solution (alpha [0.89], and a significant correlation with locally identified items [r = 0.51]) confirmed the good psychometric properties of the adapted BDI-II. No evidence was found to support the hypothesis that somatization was more prevalent. Lastly, caregivers of HIV affected adolescents had significantly higher scores compared to adults randomly selected from the community F(1, 121) = 23.31, p < .001 indicating the discriminative validity of the adapted BDI = II.ConclusionsWith an adapted administration procedure, the BDI-II provides an adequate measure of depressive symptoms which can be used alongside other measures for proper diagnosis in a low literacy population.

Review of the Literature on Determinants of Chemical Hazard Information Recall among Workers and Consumers

In many low and middle income countries (LMIC), workers’ and consumers’ only access to risk and hazard information in relation to the chemicals they use or work with is on the chemical label and safety data sheet. Recall of chemical hazard information is vital in order for label warnings and precautionary information to promote effective safety behaviors. A literature review, therefore, was conducted on determinants of chemical hazard information recall among workers and consumers globally. Since comprehension and recall are closely linked, the determinants of both were reviewed. Literature was reviewed from both online and print peer reviewed journals for all study designs and countries. This review indicated that the level of education, previous training and the inclusion of pictograms on the hazard communication material are all factors that contribute to the recall of hazard information. The influence of gender and age on recall is incongruent and remains to be explored. More research is required on the demographic predictors of the recall of hazard information, the effect of design and non-design factors on recall, the effect of training on the recall among low literate populations and the examining of different regions or contexts.

Detection of depression in low resource settings: validation of the Patient Health Questionnaire (PHQ-9) and cultural concepts of distress in Nepal.

BackgroundDespite recognition of the burden of disease due to mood disorders in low- and middle-income countries, there is a lack of consensus on best practices for detecting depression. Self-report screening tools, such as the Patient Health Questionnaire (PHQ-9), require modification for low literacy populations and to assure cultural and clinical validity. An alternative approach is to employ idioms of distress that are locally salient, but these are not synonymous with psychiatric categories. Therefore, our objectives were to evaluate the validity of the PHQ-9, assess the added value of using idioms of distress, and develop an algorithm for depression detection in primary care.MethodsWe conducted a transcultural translation of the PHQ-9 in Nepal using qualitative methods to achieve semantic, content, technical, and criterion equivalence. Researchers administered the Nepali PHQ-9 to randomly selected patients in a rural primary health care center. Trained psychosocial counselors administered a validated Nepali depression module of the Composite International Diagnostic Interview (CIDI) to validate the Nepali PHQ-9. Patients were also assessed for local idioms of distress including heart-mind problems (Nepali, manko samasya).ResultsAmong 125 primary care patients, 17 (14 %) were positive for a major depressive episode in the prior 2 weeks based on CIDI administration. With a Nepali PHQ-9 cutoff ≥ 10: sensitivity = 0.94, specificity = 0.80, positive predictive value (PPV) =0.42, negative predictive value (NPV) =0.99, positive likelihood ratio = 4.62, and negative likelihood ratio = 0.07. For heart-mind problems: sensitivity = 0.94, specificity = 0.27, PPV = 0.17, NPV = 0.97. With an algorithm comprising two screening questions (1. presence of heart-mind problems and 2. function impairment due to heart-mind problems) to determine who should receive the full PHQ-9, the number of patients requiring administration of the PHQ-9 could be reduced by 50 %, PHQ-9 false positives would be reduced by 18 %, and 88 % of patients with depression would be correctly identified.ConclusionCombining idioms of distress with a transculturally-translated depression screener increases efficiency and maintains accuracy for high levels of detection. The algorithm reduces the time needed for primary healthcare staff to verbally administer the tool for patients with limited literacy. The burden of false positives is comparable to rates in high-income countries and is a limitation for universal primary care screening.Electronic supplementary materialThe online version of this article (doi:10.1186/s12888-016-0768-y) contains supplementary material, which is available to authorized users.

Don't assume the patient understands: Qualitative analysis of the challenges low health literate patients face in the pharmacy.

Low health literacy populations have difficulty understanding health information and making appropriate health decisions. Pharmacists need to ensure patients have a basic understanding of how to take their medications and understand the risks and benefits of their prescriptions. To explore the major challenges low health literate adults face when trying to understand their medication therapy. One-on-one semi-structured interviews were used to gather data on the major challenges low health literate adults face regarding their medication. Each interview began with a verbal health literacy assessment, followed by open-ended questions focused on medication information. After each interview was complete, a written health literacy assessment was given in English, which was later used to compare self-assessed health literacy to written health literacy scores. All interviews were audio-recorded, transcribed and analyzed using thematic analysis. The population sample had an average age of 67 years old and 90% had been education outside of North America. Low health literacy levels were found in 75% of participants based on the S-TOFHLA and demonstrated a generally over estimated self-assessed health literacy levels. After thematic analysis, a flow chart that describes the low health literate population's pharmacy experience with medication information was developed to explain the cause and effect of challenges faced with current pharmacy medicationinformation. Also, the major challenges patients with low health literacy face with current medication information from the pharmacy were limited time with pharmacists, understanding medication information, forgetting to take medication, side effects and food-drug interactions. Future interventions targeted to improving pharmacy medication information for the low health literate population should focus on addressing the challenges with limited time with pharmacists, poor understanding of medication information, forgetting to take medications, side effects and food instruction/interactions.

A pilot test of the acceptability and efficacy of narrative and non-narrative health education materials in a low health literacy population

Although entertainment-education narratives are increasingly being used to communicate health information to a diversity of populations, there is limited evidence examining the use of narrative health education videos in low compared with adequate health literacy populations. There are also very few studies directly comparing narrative materials to more traditional, non-narrative materials. Because individuals with low health literacy are less likely than those with adequate health literacy to benefit from health communication interventions, it is especially important to develop an evidence base supporting the use of narrative health education materials in low-literacy populations. This study extends knowledge on the use of narrative health education materials in populations with low health literacy by conducting a randomized trial comparing the acceptability and efficacy (knowledge gain) of two fact-equivalent films, one in a narrative and one in a non-narrative format, on individuals with adequate and low health literacy. This study finds that while both films were well-accepted and produced knowledge gains, the narrative film was more effective in this regard. This effect occurred regardless of health literacy level, indicating that narrative health communication materials are appropriate for individuals with low health literacy and do not exacerbate existing health disparities. These findings add to a small but growing body of evidence testing narrative health education materials in individuals with low health literacy, and provide new evidence supporting narrative, entertainment-education style video as a health communication tool to help reduce health literacy-related health disparities.

Factors associated with cervical cancer screening in a safety net population.

AIMTo identify factors associated with Papanicolaou-smear (Pap-smear) cervical cancer screening rates in a safety net population.METHODSFrom January 2012 to May 2013, the use of Pap-smear was determined for all patients seen at the breast clinic in a safety net hospital. Health literacy assessment was performed using the validated Newest Vital Sign. The records of patients were reviewed to determine if they had undergone Pap-smears for cervical cancer screening. Sociodemographic information was collected included age, education, monthly income, race/ethnicity, employment, insurance status, and primary care provider of the patient. Logistic regression analysis was then performed to determine factors associated with utilization of Pap-smears. Crude and adjusted odds ratios derived from multivariate logistic regression models were calculated as well as the associated 95%CIs and P-values.RESULTSOverall, 39% had Pap-smears in the prior 15 mo, 1377 consecutive women were seen during the study period and their records were reviewed. Significantly more patients with adequate health literacy underwent Pap-smears as compared to those with limited health literacy (59% vs 34%, P < 0.0001). In multivariate analysis, patients with adequate health literacy, younger patients, and those with later age of first live birth were more likely to undergo Pap-smears. Patients whose primary care providers were gynecologists were also significantly more likely to have Pap-smears compared to other specialties (P < 0.0001). Patients younger than 21 years or older than 65 years underwent screening less frequently (11% and 11%, respectively) than those 21-64 years (41%, P < 0.0001). Race, ethnicity, language, and insurance status were not associated with Pap-smear screening rates.CONCLUSIONPatient health literacy and primary care physician were associated with Pap-smear utilization. Development of interventions to target low health literacy populations could improve cervical cancer screening.

Design considerations for integrating video into tablet-based mHealth interventions addressing HIV and substance use

Aims: To improve the reach and effectiveness of tablet-based mHealth interventions. Methods:mHealth interventions via tablet computer can reach patients who might otherwise be missed, and video may be especially effective with low literacy populations. However, tablets may not readily accommodate video. Understanding technical limitations, and how to address them, can potentially lead to more effective mHealth tools. The following considerations apply to interventions addressingHIV, druguse, andother behavioral health issues. Consider the Internet connection. Many tablets require Internet connections to play video. Older iPads could cache, or store video, after an initial Internet connection. This meant they could play video offline beyond the reach of WIFI or mobile broadband. Newer iPads and Android tablets do not play video without an active Internet connection. This may limit the locations in which they can be used for mHealth. Tablets that use the Windows operating system can play video from removable media, i.e. an SD card, so they can be used in locations where Internet access is not available. Develop a hybrid design. Flexible mHealth interventions can be created to work in situations where Internet connections may available sporadically or not at all. Interventions that can play videowithout a connection and then transmit data asynchronously when an Internet connection is available (possibly in another location) may address barriers to access. Think about scale. Successful mHealth interventions canbe offered simultaneously inmany locations. Designing for multiple contingencies may facilitate wider adoption. Evaluate using mixed methods. Examining howmany participants complete an intervention, and whether participants stop at the same point, may provide measures of feasibility. Qualitative interviews with participants and staff may informmore successful future interventions. Conclusions: Technology issues that could otherwise emerge as barriers can be used to optimize designs for a specific setting, population, or behavioral health issue. Financial support: NIDA R34DA037129; P30 DA011041.

VALIDATION OF THE IDEA COGNITIVE SCREENING TOOL FOR OLDER ADULTS IN HOSPITAL INPATIENT, OUTPATIENT AND RURAL COMMUNITY SETTINGS IN TANZANIA

ObjectiveThe IDEA study cognitive screening tool was developed for identification of dementia in low-resource settings and populations with low levels of formal education. The aim of this study was to...

Diabetes Health Literacy Among Somali Patients with Diabetes Mellitus in a US Primary Care Setting.

The purpose of this study was to describe diabetes literacy among Somali immigrants with diabetes and its association with diabetes outcomes. Among Somali immigrants in North America, the prevalence of diabetes exceeds that of the general population, and their measures of diabetes control are suboptimal when compared with non-Somali patients. Diabetes literacy is an important mediator of diabetes outcomes in general populations that has not been previously described among Somali immigrants and refugees. Diabetes literacy was measured using a translated version of the spoken knowledge in low literacy in diabetes (SKILLD) scale among Somali immigrants and refugees with type 2 diabetes. Diabetes outcome measures, including hemoglobin A1C, low-density lipoprotein (LDL) cholesterol, and blood pressure, were obtained for each patient. Multivariate logistic regression was used to assess associations between diabetes literacy and diabetes outcomes. Among 50 Somali patients with diabetes who completed the survey, the mean SKILLD score was low (42.2%). The diabetes outcome measures showed a mean hemoglobin A1C of 8%, LDL cholesterol of 99.17mg/dL (2.57mmol/L), systolic blood pressure of 130.9mmHg, and diastolic blood pressure of 70.2mmHg. There was no association between diabetes literacy scores and diabetes outcome measures. Somali patients with diabetes mellitus had low diabetes literacy and suboptimal measures of diabetes disease control. However, we found no association between diabetes literacy and diabetes outcomes. Future work aimed at reduction of diabetes-related health disparities among Somali immigrants and refugees to high-income countries should go beyond traditional means of patient education for low-literacy populations.

Readability of Written Materials for CKD Patients: A Systematic Review

The "average" patient has a literacy level of US grade 8 (age 13-14 years), but this may be lower for people with chronic kidney disease (CKD). Current guidelines suggest that patient education materials should be pitched at a literacy level of around 5th grade (age 10-11 years). This study aims to evaluate the readability of written materials targeted at patients with CKD. Systematic review. Patient information materials aimed at adults with CKD and written in English. Patient education materials designed to be printed and read, sourced from practices in Australia and online at all known websites run by relevant international CKD organizations during March 2014. Quantitative analysis of readability using Lexile Analyzer and Flesch-Kincaid tools. We analyzed 80 materials. Both Lexile Analyzer and Flesch-Kincaid analyses suggested that most materials required a minimum of grade 9 (age 14-15 years) schooling to read them. Only 5% of materials were pitched at the recommended level (grade 5). Readability formulas have inherent limitations and do not account for visual information. We did not consider other media through which patients with CKD may access information. Although the study covered materials from the United States, United Kingdom, and Australia, all non-Internet materials were sourced locally, and it is possible that some international paper-based materials were missed. Generalizability may be limited due to exclusion of non-English materials. These findings suggest that patient information materials aimed at patients with CKD are pitched above the average patient's literacy level. This issue is compounded by cognitive decline in patients with CKD, who may have lower literacy than the average patient. It suggests that information providers need to consider their audience more carefully when preparing patient information materials, including user testing with a low-literacy patient population.

Adherence to diabetes care

Adherence to diabetes care

Implementation of a diabetes education kiosk in a low-income clinical setting: a community implementation process.

The rapid rise in rates of diabetes among the U.S. population1 underscores the crucial need for assistance in everyday self-management of chronic illness.2,3 Yet, a major gap exists in the dissemination and implementation of research findings on 1 ) the extent to which communities are aware of best practice guidelines for diabetes prevention and management and 2 ) strategies for assisting communities in adopting identified best practices.4 A community needs assessment of key stakeholders in central Texas revealed a need for diabetes patient education in low-literacy rural communities because of residents' limited access to trained educators for diabetes self-management.5 In an effort to address the double challenges of limited access to health care providers (HCPs) and insufficient educational materials for disadvantaged, at-risk populations, the Diabetes Prevention and Management Program (DPMP) at the Center for Community Health Development6 developed a low-literacy, touch-screen computer module, the Diabetes Education Kiosk (DEK). The DEK is a form of interactive behavior-change technology (IBCT) designed to encourage healthy behavior changes by motivating patients to be more independent and improve their self-management with little or no assistance from their HCPs.7 IBCT can also improve communication between patients and health care teams by facilitating clinicians' review of patients' status and guiding delivery of educational messages.8 IBCTs include the use of hardware and software to promote and sustain behavior changes. Examples include e-mail messages, patient-centered websites, personal digital assistants, DVDs, smartphone and iPad applications, voice-response or automated phone calls, and touch-screen kiosks. Touch-screen kiosks or monitors have been used effectively for health education and other medical purposes.9–12 This article describes the pilot implementation of a computer-based touch-screen diabetes educational training tool in a central Texas family medicine residency training clinical setting that serves predominantly low-income and low-literacy patient populations. …

To What did They Consent? Understanding Consent Among Low Literacy Participants in a Microbicide Feasibility Study in Mazabuka, Zambia.

We conducted a study to review the consenting process in a vaginal microbicide feasibility study conducted in Mazabuka, Zambia. Participants were drawn from those participating in the microbicide study. A questionnaire and focus group discussion were used to collect information on participants' understanding of study aims, risks and benefits. Altogether, 200 participants took part in this study. The results of the study showed that while all participants signed or endorsed their thumbprints to the consent forms, full informed consent was not attained from most of the participants since 77% (n = 154) of the participants had numerous questions about the study and 34% (n = 68) did not know who to get in touch with concerning the study. Study objectives were not fully understood by over 61% of the participants. Sixty four percent of the participants were not sure of the risks of taking part in the microbicide study. A significant number thought the study was all about determining their HIV status. Some participants were concerned that their partners were not on the trial as they were convinced that being on the study meant that that they had a lifetime protection from HIV infection. The process of obtaining consent was inadequate as various phases of the study were not fully understood. We recommend the need for researchers to reinforce the consenting process in all studies and more so when studies are conducted in low literacy populations.

Trial participants' understanding of randomization, double-blinding, and placebo use in low literacy populations: findings from a study conducted within a microbicide trial in Malawi.

Concerns have been raised about the limits of understanding of consent by clinical trial participants in developing countries. Consequently, this empirical study was conducted in Malawi to assess microbicide trial participants' understanding of randomization, double-blinding, and placebo use. The study used a combination of quantitative and qualitative methods, including structured questionnaire interviews with a random sample of 203 individual participants, four in-depth interviews with research nurses, and two focus group discussions with 18 study participants. Most respondents earned high scores on questions related to randomization (85%) and placebo use (72%), while a greater proportion of the same respondents obtained low scores on questions related to double-blinding (68%) and personal implications of the study procedures (63%). Overall, most respondents (61%; n = 124) obtained low scores on combined understanding of all the three concepts under study.

Digitised audio questionnaire for assessment of informed consent comprehension in a low-literacy African research population: development and psychometric evaluation

ObjectiveTo develop and psychometrically evaluate an audio digitised tool for assessment of comprehension of informed consent among low-literacy Gambian research participants.SettingWe conducted this study in the Gambia where a high...

Is health literacy related to health behaviors and cell phone usage patterns among the text4baby target population?

BackgroundText4baby provides educational text messages to pregnant and postpartum women and targets underserved women. The primary purpose of this study is to examine the health behaviors and cell phone usage patterns of a text4baby target population and the associations with health literacy.MethodsPregnant and postpartum women were recruited from two Women, Infant and Children clinics in Atlanta. Women were asked about their demographics, selected pregnancy or postpartum health behaviors, and cell phone usage patterns. Health literacy skills were measured with the English version of the Newest Vital Sign. Multivariable logistic regression was used to examine health behaviors and cell usage patterns by health literacy classification, controlling for commonly accepted confounders.ResultsFour hundred sixty-eight women were recruited, and 445 completed the Newest Vital Sign. Of these, 22% had inadequate health literacy, 50% had intermediate health literacy, and 28% had adequate health literacy skills. Compared to adequate health literacy, limited literacy was independently associated with not taking a daily vitamin during pregnancy (OR 3.6, 95% CI: 1.6, 8.5) and never breastfeeding their infant (OR 1.4, 95% CI: 1.1, 1.8). The majority (69.4%) of respondents received nine or more text messages a day prior to enrollment, one in four participants (24.6%) had changed their number within the last six months, and 7.0% of study participants shared a cell phone. Controlling for potentially confounding factors, those with limited health literacy were more likely to share a cell phone than those with adequate health literacy (OR 2.57, 95% CI: 1.79, 3.69).ConclusionsText4baby messages should be appropriate for low health literacy levels, especially as this population may have higher prevalence of targeted unhealthy behaviors. Text4baby and other mhealth programs targetting low health literacy populations should also be aware of the different ways that these populations use their cell phones, including: sharing cell phones, which may mean participants will not receive messages or have special privacy concerns; frequently changing cell phone numbers which could lead to higher drop-off rates; and the penetrance of text messages in a population that receives many messages daily.

Testing efficacy of teaching food safety and identifying variables that affect learning in a low-literacy population.

Nurses at a meeting of the Asociación de Hemato Oncología Pediátrica de Centroamérica y El Caribe recognized food safety as one of the main issues affecting patient care. The objective was to increase awareness of food safety issues among caregivers for pediatric cancer patients in Guatemala and El Salvador. A low-literacy booklet about food safety, "Alimentación del niño con cáncer (Feeding the child with cancer)," was developed for caregivers. Tests were developed to assess information acquisition and retention. An educator's guide was developed for consistency of education along with a demographics questionnaire. The efficacy of the booklet was tested with 162 caregivers of patients with newly diagnosed leukemia. Information retention was tested 1 and 3months after the initial education. The booklet was found to be efficient for food safety education. There was no significant difference between post-educational knowledge in either country at 1month or in Guatemala at 3months. Pre-educational knowledge was not associated with any demographic variable except for self-reported ability to read in El Salvador. There was no significant association between learning ability and demographic variables in either country. Caregivers from El Salvador had a better ability to learn than caregivers from Guatemala. Education using the booklet greatly improved food safety knowledge, which remained high 1 and 3months later. Education with the booklet was efficacious for teaching a low-literacy population about food safety. However, it is unknown which part of the education contributed to the significant improvement in knowledge.