How Do Patients Understand Questions about Lower Urinary Tract Symptoms? A Qualitative Study of Problems in Completing Urological Questionnaires.

Lower urinary tract symptoms are common complaints in ageing people. For a urological evaluation of such complaints in men, the International Prostate Symptom Score (IPSS) is used worldwide. Previous quantitative studies have revealed serious problems in completing this questionnaire. In order to gain insight into the nature and causes of these problems, we conducted a qualitative study. Not only the purely verbal IPSS was studied but also two alternatives, including pictograms: the Visual Prostate Symptom Score (VPSS) and the Score Visuel Prostatique en Image (SVPI). Men aged 40 years and over with an inadequate level of health literacy (IHL; n = 18) or an adequate level of health literacy (AHL; n = 47) participated. Each participant filled out one of the three questionnaires while thinking aloud. The analysis of their utterances revealed problems in both health literacy groups with form-filling tasks and subtasks for all three questionnaires. Most noticeable were the problems with the IPSS; the terminology and layout of this form led to difficulties. In the VPSS and SVPI, the pictograms sometimes raised problems. As in previous research on form-filling behavior, an overestimation by form designers of form fillers' knowledge and skills seems to be an important explanation for the problems observed.

Deploying a Fotonovela to Combat Methamphetamine Abuse among South Africans with Varying Levels of Health Literacy.

Poor health literacy in the Western Cape Province of South Africa is one of the main factors hampering methamphetamine (MA) use prevention efforts in the area, where the abuse of this drug is a major health and social problem affecting especially previously disadvantaged communities. In the first part of a two-part study, we compared a health-related fotonovela about MA to an existing brochure group and a control group. Main findings show that the vast majority of readers preferred the fotonovela over the existing brochure. This included participants from all three age groups and for both levels of health literacy (low/high) distinguished (n = 372). Furthermore, specifically for older people with low levels of health literacy, the fotonovela outperformed the existing brochure condition for knowledge level. In the second part of the study, we found that healthcare providers (n = 75) strongly prefer a fotonovela over an existing brochure, while this cohort viewed the potential use of fotonovelas in a health care setting as very positive. Our findings add to the promising results of an earlier fotonovela study about MA use in South Africa, providing further support for considering using narratives in health communication as a serious option to effectively communicate convincing health information about this drug to target audiences in the Western Cape Province.

Improving Health Literacy Responsiveness: A Randomized Study on the Uptake of Brochures on Doctor-Patient Communication in Primary Health Care Waiting Rooms.

Presenting attractive and useful health education materials in waiting rooms can help improve an organization's health literacy responsiveness. However, it is unclear to what extent patients may be interested in health education materials, such as brochures. We conducted a three-week field study in waiting rooms of three primary care centers in Groningen. Three versions of a brochure on doctor-patient communication were randomly distributed, 2250 in total. One version contained six short photo stories, another version was non-narrative but contained comparable photos, and the third version was a traditional brochure. Each day we counted how many brochures were taken. We also asked patients (N = 471) to participate in a brief interview. Patients who consented (N = 390) were asked if they had noticed the brochure. If yes (N = 135), they were asked why they had or had not browsed the brochure, and why they had or had not taken it. Interview responses were categorized by two authors. Only 2.9% of the brochures were taken; no significant association with brochure version was found. Analysis of the interview data showed that the version with the photo narrative was noticed significantly more often than the non-narrative version or the traditional version. These results suggest that designing attractive and comprehensible health materials is not enough. Healthcare organizations should also create effective strategies to reach their target population.

Using a fotonovela to battle crystal meth in South Africa.

This study evaluated the effects of a health-related fotonovela about crystal meth (S-methamphetamine hydrochloride) among "Colored" people (an ethnic label for people of mixed race) in the Western Cape province of South Africa. Crystal meth use is most common among Colored people in this province and it is considered a major social problem. The fotonovela was compared to a no-message control group and a traditional brochure in a randomized controlled trial (N = 303). The fotonovela outperformed the control condition for knowledge level and it outperformed the traditional brochure on intention toward starting conversations about crystal meth. Especially readers with relatively low levels of education clearly preferred the fotonovela over the traditional brochure.

Using Photo Stories to Support Doctor-Patient Communication: Evaluating a Communicative Health Literacy Intervention for Older Adults.

Older adults often have limited health literacy and experience difficulties in communicating about their health. In view of the need for efficacious interventions, we compared a narrative photo story booklet regarding doctor-patient communication with a non-narrative but otherwise highly similar brochure. The photo story booklet included seven short picture-based stories about themes related to doctor-patient communication. The non-narrative brochure had comparable pictures and layout and dealt with the same themes, but it did not include any stories. We conducted two Randomized Controlled Trials (RCTs) among older adults with varying levels of health literacy: one RCT in Germany (N = 66) and one RCT in the Netherlands (N = 54); the latter one was followed by an in-depth interview study among a subset of the participants (81.5%; n = 44). In the RCTs, we did not find significant differences between the photo story booklet and the non-narrative brochure. In the interview study, a majority of the participants expressed a preference for the photo story booklet, which was perceived as recognizable, relevant, entertaining and engaging. We conclude that photo story booklets are a promising format but that there is room for improving their effectiveness.

"Hey, that could be me": The role of similarity in narrative persuasion.

Stories are often used in health communication because of accumulating evidence of their potential to affect people's attitudes and health behavioral intentions. Similarity between the reader and the story's protagonist appears to positively influence narrative persuasion, but the exact role of similarity on persuasive outcomes is debated, as some research finds clear effects of similarity manipulations whereas others do not. Possibly, these mixed results were found because the similarity manipulations were not always relevant to the topic of the story. We conducted an experiment (N = 582) in which we varied the age and gender of the protagonist, features that were of central relevance to the story's topic, namely breast cancer versus testicular cancer. There were two groups of participants: 324 students (mean age: 21.46 years) and 258 older adults (mean age: 56.83 years). Age similarity (but not gender similarity) had an effect on identification with the protagonist, transportation (i.e. the experience of being absorbed into a story), and the intention to donate, but only for students. For older adults, age or gender of the protagonist did not seem to matter, as nearly no differences in persuasive measures were found. As far as the underlying mechanism is concerned, the results of structural equation modeling showed that the concept of 'perceived similarity' would be a relevant addition to models of narrative persuasion, as it was significantly related to the narrative processes of transportation and identification, which, in turn, predicted attitudes and behavioral intentions, both directly-in the case of transportation-or indirectly, via the emotion of compassion. We conclude that both manipulated and perceived similarity are important for narrative persuasion, and that it should be kept on the research agenda of health communication.

Health literacy among older adults is associated with their 10-years' cognitive functioning and decline - the Doetinchem Cohort Study.

BACKGROUND: Many older adults have low levels of health literacy which affects their ability to participate optimally in healthcare. It is unclear how cognitive decline contributes to health literacy. To study this, longitudinal data are needed. The aim of this study was therefore to assess the associations of cognitive functioning and 10-years' cognitive decline with health literacy in older adults. METHODS: Data from 988 participants (mean age = 65.3) of the Doetinchem Cohort Study were analyzed. Health literacy was measured by the Brief Health Literacy Screening. Memory, mental flexibility, information processing speed, and global cognitive functioning were assessed at the same time as health literacy and also 10 years earlier. Logistic regression analyses were performed, adjusted for age, gender, and educational level. RESULTS: Higher scores on tests in all cognitive domains were associated with a lower likelihood of having low health literacy after adjustment for confounders (all ORs < 0.70, p-values<.001). Similar associations were found for past cognitive functioning (all ORs < 0.75, p-values<.05). Before adjustment, stronger cognitive decline was associated with a greater likelihood of having low health literacy (all ORs > 1.37, p-values<.05). These associations lost significance after adjustment for educational level, except for the association of memory decline (OR = 1.40, p = .023, 95% CI: 1.05 to 1.88). CONCLUSION: Older adults with poorer cognitive functioning and stronger cognitive decline are at risk for having low health literacy, which can affect their abilities to promote health and self-manage disease. Low health literacy and declining cognitive functioning might be a barrier for person-centered care, even in relatively young older adults.

Sweet Temptations: How Does Reading a Fotonovela About Diabetes Affect Dutch Adults with Different Levels of Literacy?

Recent studies suggest that health-related fotonovelas-booklets that portray a dramatic story using photographs and captions-may be effective health communication tools, especially for readers with a low level of literacy. In this experiment, effects on knowledge and behavioral intentions were assessed of a fotonovela originally developed for a Latin-American audience. Dutch readers from a low literacy group (N = 89) and a high literacy group (N = 113) were randomly assigned to one of three conditions: a fotonovela condition (all captions translated into Dutch), a traditional brochure condition (also in Dutch), and a control condition. On knowledge about diabetes, participants in the fotonovela condition outperformed participants in both other conditions. This finding was consistent across literacy levels. On behavioral intentions, however, readers of the fotonovela did not score significantly higher than participants in the other conditions. We also evaluated hypotheses proposed in the Entertainment Overcoming Resistance Model (EORM; Moyer-Gusé, 2008) on the possible mechanisms underlying persuasion through narratives. No support was found for the mechanisms proposed in the EORM. The outcomes of this study suggest that a fotonovela may be a valuable health education format for adults with varying levels of literacy, even if it was developed for a target group with a different cultural background.

Using a narrative to spark safer sex communication.

OBJECTIVE: College students are a group at risk for contracting sexually transmitted infections (STIs). While they are generally well informed about STIs, they do not consistently use condoms. An important element in preventing STIs is safer sex communication, especially with a sexual partner. This may be difficult, however, because of a lack of experience in talking about safer sex or because of the absence of suitable role models. In this study, a narrative intervention was tested that was developed to provide receivers with a social script for safer sex communication. DESIGN: An experiment was conducted among college students (N = 225) who were exposed to either a narrative intervention or a non-narrative (brochure) intervention, followed by a post-test questionnaire. In the narrative condition, part of the participants completed a pre-test questionnaire before being exposed to the intervention. RESULTS: Compared to pre-test scores, the narrative positively influenced safer sex communication intentions. The results show no significant differences between post-test scores of the narrative and the non-narrative condition. Mediation analyses showed that narrative processes (identification and transportation) were positively related to safer sex communication. CONCLUSION: In this study, we investigated both the effects of a narrative intervention on safer sex communication intentions, and the mechanisms of narrative processing underlying these effects. The narrative turned out to be as effective as a brochure version with the same information. Our mediation analyses suggest that narratives can be made more persuasive by increasing the reader's involvement with the story as a whole, and with one of the characters in particular.

Uncovering Factors Influencing Interpersonal Health Communication.

Talking to friends, family, or peers about health issues might, among other things, increase knowledge of social norms and feelings of self-efficacy in adopting a healthier lifestyle. We often see interpersonal health communication as an important mediating factor in the effects of health campaigns on health behavior. No research has been done so far, however, on factors that influence whether and how people talk about health issues without being exposed to a health campaign first. In this exploratory study, we interviewed 12 participants about their communication behavior concerning six different health themes, like smoking and exercising. The results suggest that at least four types of interpersonal health communication can be distinguished, each influenced by different factors, like conversational partner and objective of the conversation. Future research should take this diversity of interpersonal health communication into account, and focus on designing health campaigns that aim to trigger dialogue within target populations.

Development of a Communication Intervention for Older Adults With Limited Health Literacy: Photo Stories to Support Doctor-Patient Communication.

Successful doctor-patient communication relies on appropriate levels of communicative health literacy, the ability to deal with and communicate about health information. This article aims to describe the development of a narrative- and picture-based health literacy intervention intended to support older patients with limited health literacy when communicating during their primary care consultations. We performed a formative evaluation that included a review of the literature and interviews with stakeholders on relevant health literacy issues, qualitative studies with the target group, intervention planning, and a small-scale evaluation. Cocreation with the target group was a major component. Seven photo stories were developed incorporating principles from narrative and social learning theory and covering communication themes and strategies identified during focus group discussions and role-play exercises. The intervention was developed in 3 different formats: 1-page photo stories, narrated video clips using the original photo story pictures, and interactive video clips covering participation and communication during primary care consultations. In our small-scale evaluation, older adults considered the cocreated intervention appealing and comprehensible. The intervention shows promise for improving the health of older adults but needs further evaluation. This study provides a rigorous template for the participatory development of health literacy interventions.

Health Literacy Is Associated With Health Behaviors and Social Factors Among Older Adults: Results from the LifeLines Cohort Study.

This study assesses the associations between health literacy and various health behaviors and social factors among older adults, and whether social factors moderate the other associations. Data from 3,241 participants in the LifeLines Cohort Study were analyzed (mean baseline age = 68.9 years). Data on health literacy, health behaviors (physical activity, fruit and vegetable consumption, smoking, breakfast consumption, alcohol consumption, and body mass index (BMI), and social factors (loneliness, social support, social activities, social contacts, and living situation) were collected in three waves. Logistic regression analyses were used, adjusted for age and gender. Low health literacy was associated with insufficient physical activity, insufficient fruit and vegetable consumption, lack of regular breakfast consumption, obesity (odds ratios (ORs) > 1.31, p-values < .005) and low alcohol use (OR = 0.81, p = .013), but not with smoking. Low health literacy was also associated with greater loneliness, engaging in fewer social activities, and having fewer social contacts (ORs > 1.48, p-values < .005), but not with social support or living situation. Only the association between health literacy and smoking was moderated by social contacts, but this finding needs confirmation in future studies. In conclusion, low health literacy is negatively associated with health behaviors and social factors in older adults, but social factors seldom moderate the associations between health literacy and health behaviors.

Comprehensibility of Health-Related Documents for Older Adults with Different Levels of Health Literacy: A Systematic Review.

A systematic review was conducted to assess the available evidence for the effectiveness of interventions aiming to improve the comprehensibility of health-related documents in older adults (≥50) with different levels of health literacy. Seven databases were searched (2005 forward), and references in relevant reviews were checked. The selection procedure was conducted by 2 independent reviewers. Data extraction and assessment of the quality of the resulting studies were conducted by 1 reviewer and checked for accuracy by a 2nd reviewer. A total of 38 intervention studies had a study population of older adults (n = 35) or made an explicit comparison between age groups, including older adults (n = 3). Inconsistent evidence was found for the importance of design features to enhance the comprehensibility of health-related documents. Only for narratives and multiple-feature revisions (e.g., combining revisions in textual and visual characteristics) did the included studies provide evidence that they may be effective for older adults. Using narrative formats and/or multiple-feature revisions of health-related documents seem to be promising strategies for enhancing the comprehensibility of health-related documents for older adults. The lack of consistent evidence for effective interventions stresses the importance of (a) replication and (b) the use of standardized research methodologies.

The association of health literacy with adherence in older adults, and its role in interventions: a systematic meta-review.

BACKGROUND: Low health literacy is a common problem among older adults. It is often suggested to be associated with poor adherence. This suggested association implies a need for effective adherence interventions in low health literate people. However, previous reviews show mixed results on the association between low health literacy and poor adherence. A systematic meta-review of systematic reviews was conducted to study the association between health literacy and adherence in adults above the age of 50. Evidence for the effectiveness of adherence interventions among adults in this age group with low health literacy was also explored. METHODS: Eight electronic databases (MEDLINE, ERIC, EMBASE, PsycINFO, CINAHL, DARE, the Cochrane Library, and Web of Knowledge) were searched using a variety of keywords regarding health literacy and adherence. Additionally, references of identified articles were checked. Systematic reviews were included if they assessed the association between health literacy and adherence or evaluated the effectiveness of interventions to improve adherence in older adults with low health literacy. The AMSTAR tool was used to assess the quality of the included reviews. The selection procedure, data-extraction, and quality assessment were performed by two independent reviewers. Seventeen reviews were selected for inclusion. RESULTS: Reviews varied widely in quality. Both reviews of high and low quality found only weak or mixed associations between health literacy and adherence among older adults. Reviews report on seven studies that assess the effectiveness of adherence interventions among low health literate older adults. The results suggest that some adherence interventions are effective for this group. The interventions described in the reviews focused mainly on education and on lowering the health literacy demands of adherence instructions. No conclusions could be drawn about which type of intervention could be most beneficial for this population. CONCLUSIONS: Evidence on the association between health literacy and adherence in older adults is relatively weak. Adherence interventions are potentially effective for the vulnerable population of older adults with low levels of health literacy, but the evidence on this topic is limited. Further research is needed on the association between health literacy and general health behavior, and on the effectiveness of interventions.

The association of health literacy with physical activity and nutritional behavior in older adults, and its social cognitive mediators.

Inadequate health literacy is a common problem among older adults and is associated with poor health outcomes. Insight into the association between health literacy and health behaviors may support interventions to mitigate the effects of inadequate health literacy. The authors assessed the association of health literacy with physical activity and nutritional behavior in community-dwelling older adults. The authors also assessed whether the associations between health literacy and health behaviors are mediated by social cognitive factors. Data from a study among community-dwelling older adults (55 years and older) in a relatively deprived area in The Netherlands were used (baseline n=643, response: 43%). The authors obtained data on health literacy, physical activity, fruit and vegetable consumption, and potential social cognitive mediators (attitude, self-efficacy, and risk perception). After adjustment for confounders, inadequate health literacy was marginally significantly associated with poor compliance with guidelines for physical activity (OR=1.52, p=.053) but not with poor compliance with guidelines for fruit and vegetable consumption (OR=1.20, p=.46). Self-efficacy explained 32% of the association between health literacy and compliance with physical activity guidelines. Further research may focus on self-efficacy as a target for interventions to mitigate the negative effects of inadequate health literacy.

HIV/AIDS messages as a spur for conversation among young South Africans?

HIV/AIDS messages are often deliberately puzzling so as to increase the chance for them to be used as food for conversation. The South African health organisation 'loveLife,' for instance, uses messages that include complicated rhetorical expressions in their media campaigns, reasoning that those who find the messages puzzling and wonder about their meaning will be inclined to discuss the messages with their peers. In order to test the assumption that puzzlement about health messages is related to keenness to talk about these messages, structured interviews were held with 30 black learners, ages 15 to 19, from Limpopo Province, South Africa, about the messages of six HIV/ AIDS posters and six HIV/AIDS radio advertisements from 'loveLife' or another South African health organisation. No support was found for the assumption that presenting a puzzling health message will contribute to engaging the recipients in discussion. The participants indicated that they were willing to discuss the themes addressed in either a poster or radio advertisement because they appreciated the message and felt that its content was relevant to them, rather than because the message was puzzling or difficult to understand. The participants' overall actual comprehension of the messages, however, proved to be strikingly low.