The Impact and Outcomes of Integrating Health Literacy Education Into Adult Basic Education Programs in Boston.

BACKGROUND: Adult basic education (ABE) is the national system that offers educational services in English language development, reading, writing, math, technology, and communications to adults with low literacy, limited English, or both. These services range from basic levels to high school equivalency, with specialty programs in transition to community colleges and family literacy. OBJECTIVE: This study sought to analyze the role of ABE in increasing health literacy among low literate and limited English populations and to identify effective models for teaching and learning about health in this setting. METHODS: During a 2-year period, 90 students from three ABE programs in Boston participated in health literacy classes focused on healthy eating and received prevention screening services through local public health organizations. The majority of students classified themselves as Black, African American, or Latino. Participants ranged in age from 18 to 35 years; 64% of the participants were women. The three research sites were located in the Roxbury neighborhood of Boston, where health disparities and poverty rates are disproportionately high. During the study period, researchers conducted semi-structured interviews with teachers (N = 12) from each of the participating classrooms to gather information about the students in their health classes. Researchers also conducted semi-structured interviews and focus groups (N = 9) with students at each site during the study period to examine how they described changes in their knowledge, attitudes, and actions regarding health. Researchers also conducted ethnographic field research by observing health classes at each site, which was supplemented by collecting teachers' lesson plans as well as materials produced by learners. KEY RESULTS: ABE programs are a good setting for adults with limited literacy or limited English to increase their health literacy. The programs, which provide steady learning environments over time with staff skilled in adult learning, allow students to engage with health information in the context of their everyday lives, thereby increasing the likelihood of healthier practices. CONCLUSIONS: ABE programs play a vital role in developing health literacy among low literacy populations and are part of the solution for addressing health disparities. [HLRP: Health Literacy Research and Practice. 2019;3(Suppl.):S25-S32.]. PLAIN LANGUAGE SUMMARY: This article describes the role that adult basic education plays in improving health literacy among low-literate and limited English populations. The impact and outcomes of learning about health were investigated for 90 adults in three programs in Boston where health disparity is high. The impact of different teaching/learning models also was compared.

United states acculturation and cancer patients' end-of-life care.

BACKGROUND: Culture shapes how people understand illness and death, but few studies examine whether acculturation influences patients' end-of-life treatment preferences and medical care. METHODS AND FINDINGS: In this multi-site, prospective, longitudinal cohort study of terminally-ill cancer patients and their caregivers (n = 171 dyads), trained interviewers administered the United States Acculturation Scale (USAS). The USAS is a 19-item scale developed to assess the degree of "Americanization" in first generation or non-US born caregivers of terminally-ill cancer patients. We evaluated the internal consistency, concurrent, criterion, and content validity of the USAS. We also examined whether caregivers' USAS scores predicted patients' communication, treatment preferences, and end-of-life medical care in multivariable models that corrected for significant confounding influences (e.g. education, country of origin, English proficiency). The USAS measure was internally consistent (Cronbach α = 0.98); and significantly associated with US birthplace (r = 0.66, P<0.0001). USAS scores were predictive of patients' preferences for prognostic information (AOR = 1.31, 95% CI:1.00-1.72), but not comfort asking physicians' questions about care (AOR 1.23, 95% CI:0.87-1.73). They predicted patients' preferences for feeding tubes (AOR = 0.68, 95% CI:0.49-0.99) and wish to avoid dying in an intensive care unit (AOR = 1.36, 95% CI:1.05-1.76). Scores indicating greater acculturation were also associated with increased odds of patient participation in clinical trials (AOR = 2.20, 95% CI:1.28-3.78), compared with lower USAS scores, and greater odds of patients receiving chemotherapy (AOR = 1.59, 95% CI:1.20-2.12). CONCLUSION: The USAS is a reliable and valid measure of "Americanization" associated with advanced cancer patients' end-of-life preferences and care. USAS scores indicating greater caregiver acculturation were associated with increased odds of patient participation in cancer treatment (chemotherapy, clinical trials) compared with lower scores. Future studies should examine the effects of acculturation on end-of-life care to identify patient and provider factors that explain these effects and targets for future interventions to improve care (e.g., by designing more culturally-competent health education materials).

Clinical trial participation among ethnic/racial minority and majority patients with advanced cancer: what factors most influence enrollment?

BACKGROUND: Studies using administrative data report that racial/ethnic minority patients enroll in clinical trials less frequently than white patients. We studied a cohort of terminally ill cancer patients to determine a) if racial/ethnic minority patients have lower rates of drug trial enrollment than white patients once socioeconomic characteristics are accounted for and b) what factors most influence drug trial enrollment among patients with advanced canceroverall. METHODS: Coping with Cancer (CwC) is a National Cancer Institute/National Institute of Mental Health (NCI/NIMH)-funded multisite, prospective, longitudinal study of patients with advanced cancer. Baseline interviews assessed drug trial enrollment as well as socioeconomic characteristics. Logistic regression models estimated associations between drug trial enrollment and baseline characteristics. Stepwise, backward, and subset model selection was applied to select the final model where characteristics significant at α=0.05 remained in the model. RESULTS: At a median of 4.4 months prior to death, 35 of 358 patients (9.8%) were enrolled in a drug trial. In unadjusted analyses, race/ethnicity, health insurance, performance status, recruitment site, cancer type, preference for life-extending care, and lack of end-of-life care planning were associated (p<0.05) with enrollment. In multivariable analysis, patient race/ethnicity was not significantly associated with enrollment. Patients who reported not having an end-of-life discussion (adjusted odds ratio [AOR], 0.18; 95% confidence interval [CI] 0.04-0.83) and those not wanting to discuss life expectancy (AOR, 0.31; 95%CI 0.12-0.79) were more likely to be trial enrollees. CONCLUSION: Patient race/ethnicity was not associated with clinical trial enrollment after adjustment for socioeconomic covariates. Patients with advanced cancer endorsing less engagement in end-of-life planning were more likely to be enrolled in a clinical trial.

Gender differences in the evolution of illness understanding among patients with advanced cancer.

BACKGROUND: Patient understanding of advanced metastatic disease is central to decisions about care near death. Prior studies have focused on gender differences in communication style rather than on illness understanding. OBJECTIVES: : To evaluate gender differences in terminal illness acknowledgement (TIA), understanding that the disease is incurable and the advanced stage of the disease. To evaluate gender differences in patients' reports of discussions of life expectancy with oncology providers and its effect on differences in illness understanding. METHODS: Coping with Cancer 2 patients (N = 68) were interviewed before and after a visit with their oncology providers to discuss scan results. RESULTS: At the prescan interview, there were no statistically significant gender differences in patient measures of illness understanding. At the postscan interview, women were more likely than men to recognize that their illness was incurable (Adjusted Odds Ratio, [AOR] = 5.29; P = .038), know that their cancer was at an advanced stage (AOR = 6.38; P = .013), and report having had discussions of life expectancy with their oncologist (AOR = 4.77; P = .021). Controlling discussions of life expectancy, women were more likely than men to report that their cancer was at an advanced stage (AOR = 9.53; P = .050). Controlling for gender, discussions of life expectancy were associated with higher rates of TIA (AOR = 4.65; P = .036) and higher rates of understanding that the cancer was incurable (AOR = 4.09; P = .085). CONCLUSIONS: Due largely to gender differences in communication, women over time have a better understanding of their illness than men. More frequent discussions of life expectancy should enhance illness understanding and reduce gender differences.