Health Literacy, Health Outcomes and Equity: A Trend Analysis Based on a Population Survey.

Health literacy continues to be an issue among minority groups. Population surveys are one strategy used to help better understand health disparities. The Behavioral Risk Factor Surveillance System (BRFSS) in Kansas added health literacy questions to the survey in 2012. This study examined population health literacy levels and health trends from 2012 to 2018. The health status variables included health care coverage status, general health rating, presence of chronic conditions, and length of time since the last check-up. The percentage of individuals reporting low health literacy decreased from 67% in 2012 to 51% in 2018. The percentage of participants with income levels less than $15 000 was 9% in 2012 and 7% in 2018. Health literacy was lowest among the age group 18 to 24-year-olds, those who identified as multiracial, separated, not graduated from high school, out of work for more than 1 year, income less than $10 000, with other living arrangements, and living in a suburban county of metropolitan statistical area. Additionally, many health conditions improved, and those reporting health insurance increased slightly. The study demonstrates how health literacy continues to be an issue, and how education and primary prevention are necessary to improve limited health literacy and health outcomes. Findings from both state-level and national BRFSS population surveys can help educate the public health and clinical health services workforce to provide better care and address health disparities for highrisk populations.

SARS-CoV2, the COVID-19 Pandemic and Community Perceptions.

The purpose of this study was to describe knowledge and beliefs about SARS-CoV2 and COVID-19 and explore the gaps between current media coverage of health risks and what the general public knows about the virus and its outcome. A 37-question survey was developed and administered to a community collaborative group in a Midwestern state in the United States. Fifty-three participants completed the survey. When asked where participants found their information, a majority reported the internet (33.9%, n = 18/53) and radio and/or tv (28.3%, n = 15/53). Most participants showed a basic level of COVID-19 knowledge, but few could identify the 3 most frequent symptoms of COVID-19 (7.5%, n = 4/53). The results from this study highlight the continued need for increased public health communication. Educational efforts should focus on social media and internet outlets to address COVID-19 misinformation, strategies to address vaccine hesitancy, and the associated communication gap to help address related health disparities.

Identifying Health Literacy in Kansas Using the Behavioral Risk Factor Surveillance System.

Health literacy continues to be an important research topic as part of population-based assessments for overall health issues. The objective of this continuation study was to examine the health literacy rates and health outcomes as measured by the Kansas Behavioral Risk Factor Surveillance System (BRFSS) survey. A cross-sectional research design was used. Health literacy data were extracted from the state-specific module of the BRFSS telephone survey. Demographic and health status variables were extracted from the core BRFSS dataset. The association between demographic and health status characteristics with health literacy was obtained using weighted samples in multivariable logistic regression models. As in the previous study, most respondents had moderate health literacy (61.1%), followed by high health literacy (31.4%) and low health literacy (7.5%). The demographic variables of interest included race, marital status, home ownership, insurance status, metropolitan status code, survey language, veteran status, education, employment, income, sex, and age. The health status variables included general health rating, presence of chronic conditions, and length of time since last check-up. Findings include individuals with low levels of health literacy were nearly 7 times as likely to be unsure of at least one health condition than those with high health literacy and demonstrate a broad gap in people's ability to communicate accurate information to health-care providers. Results can inform future efforts to build programs that address health disparities issues including low health literacy to provide equitable health-care services. There is a continued need for support for the creation of health literate programs.

Improving Latino Health Equity Through Spanish Language Interpreter Advocacy in Kansas.

INTRODUCTION: Federal law requires any agency receiving federal aid to take "reasonable steps" to provide meaningful access to qualified limited English proficient (LEP) individuals. However, policies for the provision of language access services, including medical interpretation, vary substantially by state. The Latino population and the number of LEP individuals in the U.S. state of Kansas have grown substantially over the past 20 years, necessitating increased attention to the state's language access policies. METHOD: Though a review of previous research, we present health disparities affecting Latinos in Kansas, examine the state's language access policies for health care, and argue that health disparities could be reduced through improved language access. FINDINGS: While Kansas reimburses health care entities for interpreter services associated with Medicaid, the state has no health care interpreter competency requirements. As a result, LEP persons, primarily Spanish speakers, may be left to navigate through complex hospital systems with inadequate guidance in their language and may be at an increased risk for medical errors due to language barriers. CONCLUSION: We suggest changes that could be implemented to improve access and reduce health disparities affecting Latinos in Kansas and across the United States, and we describe work that is currently underway to support these changes.

Validation of a Single Question Health Literacy Screening Tool for Older Adults.

Objectives: Health Literacy skills are important for people of all ages. Older adults have the lowest health literacy rates. The purpose of this study was to assess health literacy rates and validate the use of a screening tool with older adults. Methods: Participants included a convenience sample, age 65 years or older, English speaking with corrected vision of 20/100 or better and typical cognitive skills. Participants completed the 36-item Short Test of Functional Health Literacy Assessment (STOFHLA) and a single item screening (SIS) tool. Results of STOFHLA and SIS were compared using nonparametric statistics. Results: Of the 64 participants, 94% had adequate scores on the STOFHLA, while 64% self-reported confidence in filling out medical forms, p = .006, χ2 = 7.606, df(1). Conclusion: Results suggest that use of health literacy screening tools for older adults may be of value. Additional studies are needed to expand the study sample and validate the findings of this study.

Promoting Health for All Kansans Through Mass Media: Lessons Learned From a Pilot Assessment of Student Ebola Perceptions.

OBJECTIVE: We aimed to assess student knowledge of Ebola virus disease (EVD) and opinions about media coverage of EVD. METHODS: We conducted a pilot study with a cross-sectional survey and a convenience sample. RESULTS: Sixty-five college students participated in the survey and reported a low level of basic knowledge of EVD, high health literacy levels, and Internet and health professionals as sources for health information. CONCLUSION: This pilot study was an important first step to understanding students' knowledge of Ebola, common sources of health information, and health literacy levels. Results from this study highlight the need to improve health communication training and further evaluate the quality of health information dissemination via all communication sources. (Disaster Med Public Health Preparedness. 2016;10:641-643).

Health Literacy and Older Adults: A Systematic Review.

Objective: The objective of this review was to assess published literature relating to health literacy and older adults. Method: The current review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta Analyses. Results: Eight articles met inclusion criteria. All studies were conducted in urban settings in the United States. Study sample size ranged from 33 to 3,000 participants. Two studies evaluated health-related outcomes and reported significant associations between low health literacy and poorer health outcomes. Two other studies investigated the impact of health literacy on medication management, reporting mixed findings. Discussion: The findings of this review highlight the importance of working to improve health care strategies for older adults with low health literacy and highlight the need for a standardized and validated clinical health literacy screening tool for older adults.

Health Literacy Assessment of the STOFHLA: Paper versus electronic administration continuation study.

Low health literacy is associated with poor health outcomes. Research is needed to understand the mechanisms and pathways of its effects. Computer-based assessment tools may improve efficiency and cost-effectiveness of health literacy research. The objective of this preliminary study was to assess if administration of the Short Test of Functional Health Literacy in Adults (STOFHLA) through a computer-based medium was comparable to the paper-based test in terms of accuracy and time to completion. A randomized, crossover design was used to compare computer versus paper format of the STOFHLA at a Midwestern family medicine residency program. Eighty participants were initially randomized to either computer (n = 42) or paper (n = 38) format of the STOFHLA. After a 30-day washout period, participants returned to complete the other version of the STOFHLA. Data analysis revealed no significant difference between paper- and computer-based surveys (p = .9401; N = 57). The majority of participants showed "adequate" health literacy via paper- and computer-based surveys (100% and 97% of participants, respectively). Electronic administration of STOFHLA results were equivalent to the paper administration results for evaluation of adult health literacy. Future investigations should focus on expanded populations in multiple health care settings and validation of other health literacy screening tools in a clinical setting.

Family medicine residency program director expectations of procedural skills of medical school graduates.

BACKGROUND AND OBJECTIVES: Mismatch between program directors' expectations of medical school graduates and the experience of students in medical school has important implications for patient safety and medical education. We sought to define family medicine residency program directors' expectations of medical school graduates to independently perform various procedural skills and medical school graduates' self-reported competence to perform those skills at residency outset. METHODS: In July of 2011, a paper-based survey was distributed nationwide by mail to 441 family medicine residency program directors and 3,287 medical school graduates enrolled as postgraduate year 1 (PGY-1) residents in family medicine residency programs. Program director expectation of independent performance and recent medical school graduate self-reported ability to independently perform each of 40 procedures was assessed. RESULTS: Surveys were completed and returned from 186 program directors (response rate 42%) and 681 medical school graduates (response rate 21%). At least 66% of program directors expected interns to enter residency able to independently perform 15 of 40 procedures. More than 80% of new interns reported they were able to independently perform five of the 15 procedures expected by program directors. CONCLUSIONS: Incongruity exists between program director expectations and intern self-reported ability to perform common procedures. Both patient safety and medical education may be jeopardized by a mismatch of expectation and experience. Assessment of medical students prior to medical school graduation or at the start of residency training may help detect procedural skill gaps and protect patient safety.

Describing adolescent breastfeeding environments through focus groups in an urban community.

PURPOSE: Breastfeeding is a potential solution to improve health outcomes for adolescent mothers and infants. Adolescence is a risk factor for low breastfeeding rates and is associated with a higher risk for perinatal complication. This study investigated facilitators and barriers to adolescent breastfeeding initiation and duration in an urban setting. METHODS: Four, 1-hour focus groups were conducted. Twenty-nine (N = 29) adolescent mothers and pregnant adolescents participated and described attitudes toward breastfeeding, attitudes among family and friends, current knowledge, and barriers and facilitators for breastfeeding. RESULTS: Four themes emerged, including the following: behavioral histories of breastfeeding, community assets, social support, and barriers. Participants identified positive histories and community resources such as local hospitals and social services as facilitators. Lifestyle, independence, lack of support from family and primary care providers, social stigma/embarrassment, and difficulty with breastfeeding techniques were described as barriers. CONCLUSION: A comprehensive and integrated primary care and public health community effort is needed to support and improve adolescent breastfeeding. Further examination of integrated interventions focused on adolescent breastfeeding behaviors through an environmental approach is needed.

Self-reported ability to perform procedures: a comparison of allopathic and international medical school graduates.

BACKGROUND: Graduates of US allopathic and international medical schools comprise the majority of physicians who began family medicine residency in July 2011. Different procedural skills may be taught in allopathic and international medical schools leading to variation in the procedures that graduates can perform independently at the beginning of residency training. A mismatch between assigned resident tasks and procedural skills mastered during medical school may jeopardize patient safety. METHODS: A survey was distributed nationwide to 3287 family medicine residents in July 2011 to determine the proportion of graduates of allopathic and international medical schools who self-reported the ability to perform each of 41 procedures independently. RESULTS: Surveys were completed by 681 residents (response rate = 21%). The proportion of allopathic and international graduates self-reporting the ability to perform 7 ambulatory, 4 inpatient and 4 maternity care procedures was statistically significantly different. CONCLUSIONS: All graduates self-reported the ability to perform few procedural skills independently upon entry to residency. More allopathic graduates self-reported the ability to perform ambulatory procedures, whereas more international graduates self-reported the ability to perform inpatient and maternity care procedures. Evaluation of individual resident competencies is key to tailor patient care responsibilities and supervision appropriately to resident abilities.

Feasibility of a randomized controlled trial to evaluate Text Reminders for Immunization Compliance in Kids (TRICKs).

OBJECTIVE: To pilot test the Text Reminders for Immunization Compliance in Kids (TRICKs) program to evaluate its feasibility and potential to increase immunization coverage. DESIGN: Randomized controlled trial (RCT). SETTING: Pediatric clinic. PARTICIPANTS: Parents of newborns being discharged from a local hospital who intended to seek child health care at the University-sponsored pediatric resident and faculty clinic. INTERVENTION: Text message immunization reminders prior to immunization due dates. MAIN OUTCOME MEASURES: Receipt and timeliness of immunizations at 2, 4 and 6 months of age. RESULTS: Participants (N=90) were English (83%) or Spanish (17%) speaking. The majority were female (83%), on public insurance (59%), and had adequate health literacy (96%). Parents were married or a member of an unmarried couple (62%). Over 66% had a high school diploma or less. Greater numbers of intervention children received immunizations and were "on time" using per protocol analysis; though not statistically significance. Limitations include sample size, problematic text messaging software, and loss of phone service at 7 months for 40% of intervention parents. However, post-intervention interviews (N=18) indicated strong support for TRICKs; 83% found the text message reminders very helpful and 17% somewhat helpful. DISCUSSION: Pilot testing allowed us to assess processes, including recruitment, retention, and software, which will increase the success of an RCT. Software with built-in backup systems is needed for follow-up when mobile service is interrupted. However, in spite of limitations, immunization rates were higher in the text message reminder group, though not statistically significant. Parent support and interest was high. A fully powered RCT is needed with follow-up over the full 4-3-1-3-3-1 series. Based on our results, for 80% power where we expected 90% compliance in the intervention group and 80% in the control group we need 219 per group, plus increases to address drop out and loss of follow-up.

Parent opinions about use of text messaging for immunization reminders.

BACKGROUND: Adherence to childhood immunization schedules is a function of various factors. Given the increased use of technology as a strategy to increase immunization coverage, it is important to investigate how parents perceive different forms of communication, including traditional means and text-message reminders. OBJECTIVE: To examine current forms of communication about immunization information, parents' satisfaction levels with these communication modes, perceived barriers and benefits to using text messaging, and the ideal content of text messages for immunization reminders. METHODS: Structured interviews were developed and approved by two Institutional Review Boards. A convenience sample of 50 parents was recruited from two local pediatric clinics. The study included a demographics questionnaire, the shortened form of the Test of Functional Health Literacy for Adults (S-TOFHLA), questions regarding benefits and barriers of text communication from immunization providers, and preferred content for immunization reminders. Content analyses were performed on responses to barriers, benefits, and preferred content (all Cohen's kappas > 0.70). RESULTS: Respondents were mostly female (45/50, 90%), white non-Hispanic (31/50, 62%), between 20-41 years (mean = 29, SD 5), with one or two children (range 1-9). Nearly all (48/50, 96%) had an S-TOFHLA score in the "adequate" range. All parents (50/50, 100%) engaged in face-to-face contact with their child's physician at appointments, 74% (37/50) had contact via telephone, and none of the parents (0/50, 0%) used email or text messages. Most parents were satisfied with the face-to-face (48/50, 96%) and telephone (28/50, 75%) communication. Forty-nine of the 50 participants (98%) were interested in receiving immunization reminders by text message, and all parents (50/50, 100%) were willing to receive general appointment reminders by text message. Parents made 200 comments regarding text-message reminders. Benefits accounted for 63.5% of comments (127/200). The remaining 37.5% (73/200) regarded barriers; however, no barriers could be identified by 26% of participants (13/50). Parents made 172 comments regarding preferred content of text-message immunization reminders. The most frequently discussed topics were date due (50/172, 29%), general reminder (26/172, 26%), and child's name (21/172, 12%). CONCLUSIONS: Most parents were satisfied with traditional communication; however, few had experienced any alternative forms of communication regarding immunizations. Benefits of receiving text messages for immunization reminders far outweighed the barriers identified by parents. Few barriers identified were text specific. Those that were, centered on cost if parents did not have unlimited texting plans.

Prescribing information therapy: opportunity for improved physician-patient communication and patient health literacy.

BACKGROUND: Recently, experts have included information therapy (Ix) as a method for increasing clinician-patient communication, patient adherence, patient understanding of diagnosis and treatment options, and reduction in hospitalizations. METHODS: This study, a secondary, retrospective analysis of survey data, independently examined participating patient perceptions of an Ix program between two Mid-western employers. Surveys were administered through the online platform from January 1, 2006 through December 31, 2009 for Employer 1 (N = 4105) and from June 1, 2007 through December 31, 2009 for Employer 2 (N = 8123). RESULTS: Preliminary findings indicate the majority of patients were adherent to recommended treatment(s) and highly rated their physician's performance. Additionally, patients indicated that their physician's access to their questionnaire responses motivated them to improve their health literacy and change their health behaviors. Secondary data analysis indicated a positive relationship between prescribed Ix and self-reported health literacy. CONCLUSION: As Web-based Ix increases in frequency, the evaluation of patient and clinician communication is important and should be expanded to increase the benefits for both patients and clinicians.