Varying Health Literacy Levels Research Articles

Addressing Behavioral Barriers to COVID-19 Testing With Health Literacy-Sensitive eHealth Interventions: Results From 2 National Surveys and 2 Randomized Experiments.

Polymerase chain reaction (PCR) testing for COVID-19 was crucial in Australia's prevention strategy in the first 2 years of the pandemic, including required testing for symptoms, contact with cases, travel, and certain professions. However, several months into the pandemic, half of Australians were still not getting tested for respiratory symptoms, and little was known about the drivers of and barriers to COVID-19 PCR testing as a novel behavior at that time. We aimed to identify and address COVID-19 testing barriers, and test the effectiveness of multiple eHealth interventions on knowledge for people with varying health literacy levels. The intervention was developed in 4 phases. Phase 1 was a national survey conducted in June 2020 (n=1369), in which testing barriers were coded using the capability-opportunity-motivation-behavior framework. Phase 2 was a national survey conducted in November 2020 (n=2034) to estimate the prevalence of testing barriers and health literacy disparities. Phase 3 was a randomized experiment testing health literacy-sensitive written information for a wide range of barriers between February and March 2021 (n=1314), in which participants chose their top 3 barriers to testing to view a tailored intervention. Phase 4 was a randomized experiment testing 2 audio-visual interventions addressing common testing barriers for people with lower health literacy in November 2021, targeting young adults as a key group endorsing misinformation (n=1527). In phase 1, barriers were identified in all 3 categories: capability (eg, understanding which symptoms to test for), opportunity (eg, not being able to access a PCR test), and motivation (eg, not believing the symptoms are those of COVID-19). Phase 2 identified knowledge gaps for people with lower versus higher health literacy. Phase 3 found no differences between the intervention (health literacy-sensitive text for top 3 barriers) and control groups. Phase 4 showed that a fact-based animation or a TikTok-style video presenting the same facts in a humorous style increased knowledge about COVID-19 testing compared with government information. However, no differences were found for COVID-19 testing intentions. This study identified a wide range of barriers to a novel testing behavior, PCR testing for COVID-19. These barriers were prevalent even in a health system where COVID-19 testing was free and widely available. We showed that key capability barriers, such as knowledge gaps, can be improved with simple videos targeting people with lower health literacy. Additional behavior change strategies are required to address motivational issues to support testing uptake. Future research will explore health literacy strategies in the current context of self-administered rapid antigen tests. The findings may inform planning for future COVID-19 variant outbreaks and new public health emergencies where novel testing behaviors are required. Australian New Zealand Clinical Trials Registry ACTRN12621000876897, https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=382318 ; Australian New Zealand Clinical Trials Registry ACTRN12620001355965, https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=380916&isReview=true.

Does health literacy predict cardiometabolic marker trajectories among people with diabetes? A longitudinal mixed-effect analysis

AimsTo assess trajectories in cardiometabolic markers among people with type 1 and type 2 diabetes with varying health literacy levels. MethodsSurvey data assessing self-reported health literacy among 1401 people with type 1 diabetes and 910 people with type 2 diabetes were linked to prospective clinical data. Mixed effects modelling was used to identify the impact of three health literacy domains on trajectories of systolic blood pressure (SBP), low-density lipoprotein cholesterol (LDL-C), and glycated hemoglobin (HbA1c). ResultsHigh health literacy scores in some domains were associated with attenuated HbA1c trajectories, while associations with LDL-C and SBP were weak or absent, particularly among participants with type 2 diabetes. The domain “Ability to Actively Manage Health” had the strongest association with HbA1c (P < 0.001). Exponential changes over time were not observed. Differences in the estimated progression of cardiometabolic markers by health literacy levels did not reach statistical significance. ConclusionLow health literacy was associated with suboptimal glycaemic levels in type 1 and type 2 diabetes. There was inconclusive evidence of associations between health literacy, BP, and LDL-C. Development in cardiometabolic markers did not indicate faster diabetes progression among people with low health literacy.

Impact of Individualized Patient Education Material on Patients' Cancer Care Experiences

Background Patient education materials (PEMs) empower patients to have an understanding of their health and treatment options. PEMs that currently exist in Radiation Oncology are available primarily as text heavy resources, or multiple-click web-based Internet resources, exceeding the national readability recommendation of a 6th grade reading level. A health literacy level appropriate PEM that simplifies the complexity of a cancer diagnosis and treatment options may be a reasonable option to facilitate patient-provider communication in Oncology. Methods We are developing a multidisciplinary, health literacy appropriate thoracic oncology PEM at Rush University Medical Center (RUMC) in Chicago, IL, which serves a diverse patient population with varying health literacy levels. This new PEM, part of an ongoing study, aims to address the knowledge translation gap. The primary outcome is to assess the mean difference in patient satisfaction between control and study groups. The secondary outcome is to assess an interaction effect between health literacy and the overall effect of the PEM on patient satisfaction. Results This prospective randomized control trial with IRB approval is ongoing. The PEM was developed collaboration with media designers and the RUMC Patient Education Committee. Readability of the PEM was assessed with ten common readability assessment scales, represented through a mean score. All English or Spanish speaking adults scheduled for a new patient consult during Comprehensive Lung Clinic will be included. The control group will receive the standard of care (physician encounter without the PEM), while the intervention group will receive standard of care and the PEM. All patients will complete an anonymized validated survey that measures health literacy levels, sociodemographic factors, and satisfaction of the encounter. A cumulative anonymized health-care provider survey will gather descriptive data about health-care providers' experiences using the PEM. Descriptive statistics will characterize the control and study group. Patient satisfaction will be measured on a 5-point scale. A two-sample t-test with a one-sided alternative will measure the difference of mean score of patient satisfaction between the control and study group. We will apply interaction tests to determine the differential impact of health literacy on the correlation of the PEM and patient satisfaction. Multiple linear regression modeling will be done to determine the correlation of the PEM and patient satisfaction after adjusting for other socio-demographic variables. Discussion If received well, we will explore expanding this study to other treatment sites, with the overall goal of improving health literacy appropriate PEMs in Radiation Oncology. Patient education materials (PEMs) empower patients to have an understanding of their health and treatment options. PEMs that currently exist in Radiation Oncology are available primarily as text heavy resources, or multiple-click web-based Internet resources, exceeding the national readability recommendation of a 6th grade reading level. A health literacy level appropriate PEM that simplifies the complexity of a cancer diagnosis and treatment options may be a reasonable option to facilitate patient-provider communication in Oncology. We are developing a multidisciplinary, health literacy appropriate thoracic oncology PEM at Rush University Medical Center (RUMC) in Chicago, IL, which serves a diverse patient population with varying health literacy levels. This new PEM, part of an ongoing study, aims to address the knowledge translation gap. The primary outcome is to assess the mean difference in patient satisfaction between control and study groups. The secondary outcome is to assess an interaction effect between health literacy and the overall effect of the PEM on patient satisfaction. This prospective randomized control trial with IRB approval is ongoing. The PEM was developed collaboration with media designers and the RUMC Patient Education Committee. Readability of the PEM was assessed with ten common readability assessment scales, represented through a mean score. All English or Spanish speaking adults scheduled for a new patient consult during Comprehensive Lung Clinic will be included. The control group will receive the standard of care (physician encounter without the PEM), while the intervention group will receive standard of care and the PEM. All patients will complete an anonymized validated survey that measures health literacy levels, sociodemographic factors, and satisfaction of the encounter. A cumulative anonymized health-care provider survey will gather descriptive data about health-care providers' experiences using the PEM. Descriptive statistics will characterize the control and study group. Patient satisfaction will be measured on a 5-point scale. A two-sample t-test with a one-sided alternative will measure the difference of mean score of patient satisfaction between the control and study group. We will apply interaction tests to determine the differential impact of health literacy on the correlation of the PEM and patient satisfaction. Multiple linear regression modeling will be done to determine the correlation of the PEM and patient satisfaction after adjusting for other socio-demographic variables. If received well, we will explore expanding this study to other treatment sites, with the overall goal of improving health literacy appropriate PEMs in Radiation Oncology.

Health Literacy and Its Associations with Understanding and Perception of Front-of-Package Nutrition Labels among Higher Education Students

(1) Background: Nutrition labels on the front of food packages have increasingly become the focus of research. However, too few studies have placed special emphasis on nutritionally at-risk subpopulations, such as young adults or those with low literacy/numeracy skills. The present study aimed to assess both the perception and objective understanding of three front-of-package labeling (FOPL) formats currently in use on the Belgian market, i.e., the Nutri-Score, Reference Intakes, and Multiple Traffic Lights, among students of varying health literacy (HL) levels. (2) Methods: A web-based survey was carried out among 2295 students of tertiary education in the province of Liège, Belgium. The questionnaire included questions related to general characteristics, objective understanding, and perception in response to the assigned FOPL format and level of HL. (3) Results: With respect to objective understanding, the Nutri-Score outperformed all other labels across all HL levels, and it was similarly understood in students of varying HL levels. Several students’ characteristics appeared to be associated with each cluster of perception, with the Nutri-Score cluster having the highest percentages of disadvantaged students, i.e., those with inadequate HL, from non-university institutions, with low self-estimated nutrition knowledge, and with low self-estimated diet quality. (4) Conclusion: Overall, the findings supported the Nutri-Score as particularly effective in guiding students in their food choices. Of particular importance is the fact that the summarized and graded color-coded nutritional label would be a useful strategy for those disadvantaged by limited HL.

The Impact of Health Literacy-Sensitive Design and Heart Age in a Cardiovascular Disease Prevention Decision Aid: Randomized Controlled Trial and End-User Testing.

BackgroundShared decision-making is an essential principle for the prevention of cardiovascular disease (CVD), where asymptomatic people consider lifelong medication and lifestyle changes.ObjectiveThis study aims to develop and evaluate the first literacy-sensitive CVD prevention decision aid (DA) developed for people with low health literacy, and investigate the impact of literacy-sensitive design and heart age.MethodsWe developed a standard DA based on international standards. The standard DA was based on our existing general practitioner DA. The literacy-sensitive DA included simple language, supporting images, white space, and a lifestyle action plan. The control DA used Heart Foundation materials. A randomized trial included 859 people aged 45-74 years using a 3 (DA: standard, literacy-sensitive, control) ×2 (heart age: heart age + percentage risk, percentage risk only) factorial design, with outcomes including prevention intentions and behaviors, gist and verbatim knowledge of risk, credibility, emotional response, and decisional conflict. We iteratively improved the literacy-sensitive version based on end-user testing interviews with 20 people with varying health literacy levels.ResultsImmediately after the intervention (n=859), there were no differences in any outcome among the DA groups. The heart age group was less likely to have a positive emotional response, perceived the message as less credible, and had higher gist and verbatim knowledge of heart age risk but not percentage risk. After 4 weeks (n=596), the DA group had better gist knowledge of percentage risk than the control group. The literacy-sensitive DA group had higher fruit consumption, and the standard DA group had better verbatim knowledge of percentage risk. Verbatim knowledge was higher for heart age than for percentage risk among those who received both.ConclusionsThe literacy-sensitive DA resulted in increased knowledge of CVD risk and increased fruit consumption in participants with varying health literacy levels and CVD risk results. Adding heart age did not increase lifestyle change intentions or behavior but did affect psychological outcomes, consistent with previous findings. This tool will be integrated with additional resources to improve other lifestyle outcomes.Trial RegistrationAustralian New Zealand Clinical Trials Registry ACTRN12620000806965; https://tinyurl.com/226yhk8a

Exploring diabetes management behaviors among varying health literacy levels: A qualitative analysis

BackgroundDiabetes is a controllable disease, yet many adults struggle with managing this disease and are living with uncontrolled diabetes. Often, this can be attributed to patients’ inadequate health literacy affecting their diabetes management behaviors. ObjectiveThe objective of this study was to explore perceived benefits, barriers, and self-efficacy of patients to learn about the influences on diabetes management behaviors among varying health literacy levels. MethodsThis study included patients at a pharmacist-led diabetes center in Indiana. Patients were contacted via phone and asked if they would like to participate. Data were collected via a 30-minute interview. Interview questions based on the Health Belief Model were asked to assess patients’ behaviors of diabetes management. For qualitative data analysis of interviews after transcription, codes were applied using the coding software NVivo (QSR International, Burlington, MA) with a combined deductive and inductive approach taken to code creation. ResultsThere were no thematic differences in narratives of those with adequate versus inadequate health literacy regarding self-efficacy. However, participants with inadequate health literacy were more likely to rely on others to maintain self-efficacy. ConclusionsInformation gathered from this study will further the understanding of patients’ self-efficacy to manage diabetes and its influence by health literacy and support from others.

Efficacy of "High in" Nutrient Specific Front of Package Labels-A Retail Experiment with Canadians of Varying Health Literacy Levels.

Background: In 2018, Health Canada, the Federal department responsible for public health, put forward a regulatory proposal to introduce regulations requiring a “High in” front-of-package label (FOPL) on foods that exceed predetermined thresholds for sodium, sugars, or saturated fat. This study evaluated the efficacy of the proposed FOPL as a quick and easy tool for making food choices that support reduction in the intakes of these nutrients. Methods: Consumers (n = 625) of varying health literacy levels (HL) were assigned to control (current labeling with no FOPL) or one of four FOPL designs. They completed six shopping tasks, designed to control for internal motivations. Efficacy was measured with correct product selection and response time (seconds) to make food choices using repeated measures statistical modeling, adjusting for HL, task type, and task order. Eye-tracking and structured interviews were used to gather additional insights about participants’ choices. Results: Overall, FOPL was significantly more effective than current labeling at helping consumers of varying HL levels to identify foods high in nutrients of concern and make healthier food choices. All FOPL were equally effective. Conclusions: “High in” FOPL can be effective at helping Canadians of varying HL levels make more informed food choices in relation to sugars, sodium, and saturated fat.

4032 An exploration of the perceptions of young women with breast cancer with varying health literacy levels about the usefulness of cancer educational materials

OBJECTIVES/GOALS: Young women (18 – 45 years of age) with breast cancer have complex medical and psychosocial needs. Educational materials are often used as tools in patient-centered communication. However, these materials disseminate complex health information in print-heavy formats and can be difficult to understand for women with varying health literacy levels. METHODS/STUDY POPULATION: In the first phase of this study, the principal investigator (PI) will recruit 40 diverse women to participate in four focus groups (FG) to explore the perceived usefulness of the most frequently used cancer educational materials. The PI will also obtain demographics and heath literacy levels of the FG participants using the Newest Vital Sign. In the second phase, the PI will assess the literacy demands of the ten most frequently used cancer educational print materials and five most frequently used websites described by the FG participants. The perceptions of the usefulness of materials and the literacy demands will then be used to appraise the effectiveness of materials within patient-centered cancer communication. RESULTS/ANTICIPATED RESULTS: Results from this study will provide a patient-centered blueprint that will be used to design more effective educational materials that treatment centers can incorporate into their patient-centered cancer communication process. The next step of this research will be to determine providers’ perceptions of cancer education materials used to exchange information within the patient-centered communication process. This will complement the patient findings and inform the development of the provider aspect of a communication intervention centered on designing educational materials for women with various health literacy levels within the patient-centered cancer communication process. DISCUSSION/SIGNIFICANCE OF IMPACT: Detecting the usefulness of cancer educational materials, as perceived by young women with breast cancer, is foundational to developing communication interventions that improve cancer outcomes. This study will identify how materials can be improved in the critical informational-exchange component of the patient-communication process.

Validation of health literacy domains for informed decision making about colorectal cancer screening using classical test theory and item response theory

ObjectiveTo construct and validate a computer-based and performance-based instrument to assess health literacy skills for informed decision making in colorectal cancer screening among screening invitees. MethodsAn instrument was constructed based on a conceptual framework of health literacy skills in colorectal cancer screening and findings from an expert survey. The instrument was field-tested among individuals with low health literacy (n = 28). Its validity and reliability was assessed using classical test theory and item response theory approaches in an online panel of colorectal cancer screening invitees (n = 696). ResultsConfirmatory factor analysis confirmed four separate factors: Comprehension, Application, Numeracy and Communication. A fifth domain (Appraisal) demonstrated poor reliability and validity and was omitted in further analyses. Internal consistency (Cronbach’s alpha > 0.6 for the four scales) was acceptable and test-retest reliability was moderate. The four factors were measurement invariant for age, sex and educational level. ConclusionThe computer-based measures were acceptable for self-administration. The constructed multidimensional health literacy instrument showed acceptable measurement properties. Practice implicationsOur findings imply that the computer-based instrument can be used for the development of interventions to support informed decision making about colorectal cancer screening among individuals with varying health literacy levels. Further research is needed for optimizing performance-based measurement of the Appraisal and Communication domains.

Development and pilot-testing of a colorectal cancer screening decision aid for individuals with varying health literacy levels

ObjectiveMaking an informed decision about colorectal cancer screening requires health literacy. Our aim was to develop and pilot-test a computer-based decision aid to support informed decision making about whether or not to participate in colorectal cancer screening for individuals with varying health literacy levels in the Netherlands. MethodsFirst, we designed and adapted the decision aid prototype among 25 individuals with low (n = 15) and adequate (n = 10) health literacy. Second, we used a before/after study to assess changes in knowledge, attitude, intention, decisional conflict, deliberation, anxiety and risk perception in an online survey among 81 individuals eligible for colorectal cancer screening with low (n = 35) and adequate (n = 46) health literacy. ResultsThe decision aid was acceptable, comprehensible, reduced decisional conflict, increased deliberation and improved knowledge about colorectal cancer screening, but not about colorectal cancer, among individuals with adequate and low health literacy. Usability was slightly higher for participants with adequate health literacy compared to those with low health literacy. ConclusionThe decision aid is promising in supporting informed decision making about colorectal cancer screening, also among individuals with lower health literacy. Practice implicationsFurther refinement of interactive features, such as videos, animations and the values clarification exercise, is needed to increase the usability of the decision aid.

Views of parents regarding human papillomavirus vaccination: A systematic review and meta-ethnographic synthesis of qualitative literature.

Human papillomavirus (HPV) is the most common viral infection of the reproductive tract. Three prophylactic HPV vaccines are available for the prevention of HPV-related disease. Despite clinical success, immunisation rates remain sub-optimal. The purpose of this systematic review is to synthesise qualitative literature to achieve an understanding of the drivers and barriers to HPV vaccine acceptability and to determine targets for an intervention to improve vaccine uptake. The seven-step model of meta-ethnography described by Noblit and Hare was used. The quality of the studies was assessed using the CASP (Critical Appraisal Skills Programme) for qualitative research. The ENTREQ (Enhancing transparency in reporting the synthesis of qualitative research) statement was used to guide reporting of results. Thirty-three studies were included in the final analysis, compiling the opinions of 1280 parents/guardians from 14 countries. Five key concepts that reflected the principal findings of studies were determined: is prevention better than cure; the fear of the unknown; limited knowledge and understanding; complex vaccination decisions and; parental responsibility. Third-order interpretations were developed and linked using a 'line of argument' to develop a conceptual model. The majority of parents are motivated to protect their children and prevent disease. The link to sexual intercourse associated with the HPV vaccine often complicates the vaccination decision. Vaccine manufacturers, national healthcare systems and healthcare providers can reinforce the importance of HPV immunisation and reiterate the rationale behind vaccination recommendations, by providing unambiguous information in a timely manner, transparently addressing parental concerns regarding vaccine safety and efficacy, whilst taking account of cultural and religious sensitivities and varying health literacy levels. In recent years, there has been a reduction in HPV vaccine uptake worldwide. Currently, there is a paucity of published qualitative studies addressing these new vaccine concerns. Therefore, such research is required to guide intervention development, to improve HPV vaccine uptake.

The importance of building trust and tailoring interactions when meeting older adults’ health literacy needs

Purpose: Health literacy is the ability to access, understand and use health information. This study qualitatively explored the views and experiences of older adults with varying health literacy levels who had attended a falls clinic on their overall experience of the falls clinic, access to the service and provider–patient interaction.Methods: Individual semi-structured interviews were conducted with nine older adults using a falls clinic in England. Health literacy was assessed using the REALM and NVS-UK. Interviews were audio-recorded, transcribed verbatim and interrogated using interpretative phenomenological analysis (IPA).Results: Two superordinate themes emerged from the analysis: The importance of trust and relationship building to achieve effective communication with older adults; and the importance of tailoring education and healthcare to older adults’ individual health literacy needs and preferences.Conclusions: The findings corroborate previous research emphasising the importance of face-to-face communication in responding to older adults’ individual health literacy needs. Building trust in the relationship and tailoring communication to older adults’ individual attributes and preferred learning styles is essential. Healthcare practitioners and managers should consider how service organisation and communication methods can enhance positive and effective relationships with patients. Improved training could support healthcare providers in meeting patients’ personal communication needs.Implications for RehabilitationRehabilitation professionals should be aware of their patients’ individual health literacy needs and communication/learning preferences.It is important to build relationships and trust with older adults attending rehabilitation services.Further training for rehabilitation professionals could support them in meeting patients’ personal communication needs.

Health-Related Quality of Life in Heart Failure Patients With Varying Levels of Health Literacy Receiving Telemedicine and Standardized Education.

The purpose of this study was to examine the effect of telemonitoring plus education by home healthcare nurses on health-related quality of life in patients with heart failure who had varying health literacy levels. In this pretest/posttest treatment only study, 35 patients with a diagnosis of heart failure received home healthcare nurse visits, including education and telemonitoring. Heart failure education was provided by nurses at each home healthcare visit for approximately 15 to 20 minutes. All participants completed the Short-Form Test of Functional Health Literacy in Adults (S-TOFHLA) and the Minnesota Living with Heart Failure Questionnaire (MLHFQ) during the first week of home healthcare services. The MLHFQ was administered again at the completion of the covered home healthcare services period (1-3 visits per week for 10 weeks). Most participants were older adults (mean age 70.91±12.47) and had adequate health literacy (51.4%). Almost half of the participants were NYHA Class III (47.1%). All participants received individual heart failure education, but this did not result in statistically significant improvements in health-related quality-of-life scores. With telemonitoring and home healthcare nurse visits, quality-of-life scores improved by the conclusion of home healthcare services (clinically significant), but the change was not statistically significant. Individuals with marginal and inadequate health literacy ability were able to correctly use the telemonitoring devices.

Health Literacy and Computer-Assisted Instruction: Usability and Patient Preference

The authors investigated the feasibility of using computer-assisted instruction in patients of varying literacy levels by examining patients’ preferences for learning and their ability to use 2 computer-based educational programs. A total of 263 participants 50–74 years of age with varying health literacy levels interacted with 1 of 2 educational computer programs as part of a randomized trial of a colorectal cancer screening decision aid. A baseline and postprogram evaluation survey were completed. More than half (56%) of the participants had limited health literacy. Regardless of literacy level, doctors were the most commonly used source of medical information—used frequently by 85% of limited and adequate literacy patients. In multivariate logistic regression, only those with health insurance (OR = 2.35, p = .06) and computer use experience (OR = 0.39, p = .03) predicted the ability to complete the programs without assistance compared with those without health insurance or prior computer use, respectively. Although patients with limited health literacy had less computer experience, the majority completed the programs without any assistance and stated that they learned more than they would have from a brochure. Future research should investigate ways that computer-assisted instruction can be incorporated in medical care to enhance patient understanding.