Development and validation of the comprehensive health activities scale: a new approach to health literacy measurement.

Current health literacy measures have been criticized for solely measuring reading and numeracy skills when a broader set of skills is necessary for making informed health decisions, especially when information is often conveyed verbally and through multimedia video. The authors devised 9 health tasks and a corresponding 190-item assessment to more comprehensively measure health literacy skills. A sample of 826 participants between the ages of 55 and 74 years who were recruited from an academic general internal medicine practice and three federally qualified health centers in Chicago, Illinois, completed the assessment. Items were reduced using hierarchical factor analysis and item response theory resulting in the 45-item Comprehensive Health Activities Scale. All 45 items loaded on 1 general latent trait, and the resulting scale demonstrated high reliability and strong construct validity using measures of health literacy and global cognitive functioning. The predictive validity of the Comprehensive Health Activities Scale using self-reported general, physical, and mental health status was comparable to or better than widely used measures of health literacy, depending on the outcome. Despite comprehensively measuring health literacy skills, items in the Comprehensive Health Activities Scale supported 1 primary construct. With similar psychometric properties, current measures may be adequate, depending on the purpose of the assessment.

The association of health literacy with illness and medication beliefs among older adults with asthma.

OBJECTIVE: Suboptimal health literacy (HL) and asthma beliefs are associated with poor asthma self-management and outcomes. We tested the hypothesis that low HL is associated with inaccurate beliefs. METHODS: Asthmatics ≥60 were recruited from hospital and community practices in New York, NY and Chicago, IL (n=420). HL was measured with the Short Test of Functional Health Literacy in Adults; validated instruments derived from the self regulation model were used to assess beliefs. The association of beliefs with HL was evaluated with multivariate models. RESULTS: Thirty-six percent of patients had low HL; 54% believed they only have asthma when symptoms are present, 29% believed they will not always have asthma and 20% believed that their doctor can cure asthma. HL was associated with beliefs of not having asthma all the time and that asthma can be cured (OR: 1.84, 95% CI: 1.2-2.82; OR: 2.22, 95% CI: 1.29-3.82, respectively). Patients with low HL were also more likely to be concerned about medication use (ß=0.92, p=.05), despite recognizing their necessity (ß=-1.36, p=.01). CONCLUSIONS: Older asthmatics with low HL endorse erroneous asthma beliefs. PRACTICE IMPLICATIONS: Health communications for improving self-management behaviors in asthma should employ both health literacy-appropriate strategies and messages to counter illness-related misconceptions.

Literacy and race as risk factors for low rates of advance directives in older adults.

OBJECTIVES: To examine the effect of the relationship between literacy and other individual-level factors on having an advance directive (AD). DESIGN: Face-to-face structured interview. SETTING: Participants were recruited from an academic general internal medicine clinic and one of four federally qualified health centers in Chicago. PARTICIPANTS: Seven hundred eighty-four adults aged 55 to 74. MEASUREMENTS: Assessment of participant literacy, sociodemographic factors, and having an AD for medical care. RESULTS: One-eighth (12.4%) of participants with low literacy, 26.6% of those with marginal literacy, and 49.5% of those with adequate literacy reported having an AD (P < .001). In multivariable analyses, literacy and race were independently associated with less likelihood of having an AD. Specifically, participants with limited literacy (risk ratio (RR) = 0.45, 95% confidence interval (CI) = 0.22-0.95) and African Americans (RR = 0.64, 95% CI = 0.47-0.88) were less likely to have an AD. Exploratory analyses showed that there was not a significant interaction between the effect of literacy and race. CONCLUSION: Limited literacy and African-American race were significant risk factors for not having an AD in this cohort of older adults. Literacy and race probably represent two separate but important causal pathways that need to be understood to improve how the healthcare system ascertains and protects individuals' advance care preferences.

Depressive symptoms, low adherence, and poor asthma outcomes in the elderly.

OBJECTIVE: To examine the impact of depressive symptoms on asthma outcomes and medication adherence in inner-city elderly patients with asthma. METHODS: Cohort study of elderly asthmatics receiving primary care at three clinics in New York City and Chicago from 1 January 2010 to 1 January 2012. Depressive symptoms were ascertained with the Patient Health Questionnaire (PHQ-9). Outcomes included asthma control (Asthma Control Questionnaire, ACQ), asthma-related quality of life (Asthma Quality of Life Questionnaire, AQLQ), and acute resource utilization (inpatient and outpatient visits). Asthma medication adherence was evaluated using the Medication Adherence Reporting Scale (MARS). RESULTS: Three hundred and seventeen participants ≥60 years were included in the study (83% women, 30% Hispanic, and 31% Black). In unadjusted analyses, participants with depressive symptoms were more likely to report poor asthma control (p < .001), worse AQLQ scores (p < .001), and higher rates of inpatient asthma-related visits (odds ratio [OR]: 2.03, 95% confidence interval [CI]: 1.04-3.99). Those with depressive symptoms also reported lower medication adherence (OR: 0.23, 95%CI: 0.10-0.54). Similar results were obtained in analyses adjusting for age, sex, race/ethnicity, income, asthma medication prescription, years with asthma, intubation history, comorbidities, and health literacy. CONCLUSION: In this cohort of elderly inner-city participants, depressive symptoms were associated with poorer asthma control and quality of life, as well as with lower rates of adherence to controller medications. Future work exploring possible mediators, including adherence, might elucidate the relationship between depression and poorer asthma outcomes in this population.

Asthma beliefs are associated with medication adherence in older asthmatics.

BACKGROUND: Empirical research and health policies on asthma have focused on children and young adults, even though asthma morbidity and mortality are higher among older asthmatics. OBJECTIVE: To explore the relationship of asthma-related beliefs and self-reported controller medication adherence in older asthmatics. DESIGN: An observational study of asthma beliefs and self-management among older adults. PARTICIPANTS: Asthmatics ages ≥ 60 years (N = 324, mean age 67.4 ± 6.8, 28 % white, 32 % black, 30 % Hispanic) were recruited from primary care practices in New York City and Chicago. MAIN MEASURES: Self-reported controller medication adherence was assessed using the Medication Adherence Report Scale. Based on the Common Sense Model of Self-Regulation, patients were asked if they believe they only have asthma with symptoms, their physician can cure their asthma, and if their asthma will persist. Beliefs on the benefit, necessity and concerns of treatment use were also assessed. Multivariate logistic regression was used to examine the association of beliefs with self-reported medication adherence. KEY RESULTS: The majority (57.0 %) of patients reported poor adherence. Poor self-reported adherence was more common among those with erroneous beliefs about asthma illness and treatments, including the "no symptoms, no asthma" belief (58.7 % vs. 31.7 %, respectively, p < 0.001), "will not always have asthma" belief (34.8 % vs. 12.5 %, p < 0.001), and the "MD can cure asthma" belief (21.7 % vs. 9.6 %, p = 0.01). Adjusting for illness beliefs, treatment beliefs and demographics, patients with a "no symptoms, no asthma" belief had lower odds of having good self-reported adherence (odds ratio [OR] 0.45, 95 % confidence interval [CI] 0.23-0.86), as did those with negative beliefs about the benefits (OR 0.73, 95 % CI 0.57-0.94) and necessity (OR 0.89, 95 % CI 0.83-0.96) of treatment. CONCLUSIONS: Illness and treatment beliefs have a strong influence on self-reported medication adherence in older asthmatics. Interventions to improve medication adherence in older asthmatics by modifying illness and treatment beliefs warrant study.

The influence of health literacy on comprehension of a colonoscopy preparation information leaflet.

BACKGROUND: Successful bowel preparation is important for safe, efficacious, cost-effective colonoscopy procedures; however, poor preparation is common. OBJECTIVE: We sought to determine whether there was an association between health literacy and comprehension of typical written instructions on how to prepare for a colonoscopy to enable more targeted interventions in this area. DESIGN: This is a cross-sectional observational study. SETTING: This study was performed at primary care clinics and federally qualified health centers in Chicago, Illinois. PATIENTS: Seven hundred sixty-four participants (mean age, 63 years; SD, 5.42) were recruited. The sample was from a mixed sociodemographic background, and 71.9% of the participants were classified as having adequate health literacy scores. INTERVENTION: Seven hundred sixty-four participants were presented with an information leaflet outlining the bowel preparatory instructions for colonoscopy. MAIN OUTCOME MEASURES: Five questions were used to assess participants' comprehension of the instructions in an "open book" test. RESULTS: Comprehension scores on the bowel preparation items were low. The mean number of items correctly answered was 3.2 (SD, 1.2) of a possible 5. Comprehension scores overall and for each individual item differed significantly by health literacy level (all p < 0.001). After controlling for sex, age, race, socioeconomic status, and previous colonoscopy experience in a multivariable model, health literacy was a significant predictor of comprehension (inadequate vs adequate: ß = -0.2; p < 0.001; marginal vs adequate: ß = -0.2; p < 0.001). LIMITATIONS: The outcome represents a simulated task and not actual comprehension of preparation instructions for participants' own recommended behavior. CONCLUSIONS: Comprehension of a written colonoscopy preparation leaflet was generally low and significantly lower among people with low health literacy. Poor comprehension has implications for the safety and economic impact of gastroenterological procedures such as colonoscopy. Therefore, future interventions should aim to improve comprehension of complex medical information by reducing literacy-related barriers.

The association between language proficiency and outcomes of elderly patients with asthma.

BACKGROUND: Asthma is a growing cause of morbidity for elderly Americans and is highly prevalent among Hispanic people in the United States. The inability to speak English poses a barrier to patient-provider communication. OBJECTIVE: To evaluate associations between limited English proficiency, asthma self-management, and outcomes in elderly Hispanic patients. METHOD: Elderly patients with asthma receiving primary care at clinics in New York City and Chicago were studied. RESULTS: Of 268 patients in the study, 68% were non-Hispanic, 18% English-proficient Hispanic, and 14% Hispanic with limited English proficiency. Unadjusted analyses showed that Hispanic persons with limited English proficiency had worse asthma control (P = .0007), increased likelihood of inpatient visits (P = .002), and poorer quality of life (P < .0001). We also found significant associations between limited English proficiency and poorer medication adherence (P = .006). Similar results were obtained in multiple regression analyses adjusting for demographics, asthma history, comorbidities, depression, and health literacy. CONCLUSION: Limited English proficiency was associated with poorer self-management and worse outcomes among elderly patients with asthma. Further understanding of mechanisms underlying this relationship is necessary to develop interventions that improve asthma outcomes in this vulnerable population.

Comparative analysis of print and multimedia health materials: a review of the literature.

OBJECTIVE: Evaluate the evidence regarding the relative effectiveness of multimedia and print as modes of dissemination for patient education materials; examine whether development of these materials addressed health literacy. METHODS: A structured literature review utilizing Medline, PsycInfo, and the Cumulative Index to the Nursing and Allied Health Literature (CINAHL), supplemented by reference mining. RESULTS: Of 738 studies screened, 30 effectively compared multimedia and print materials. Studies offered 56 opportunities for assessing the effect of medium on various outcomes (e.g., knowledge). In 30 instances (54%), no difference was noted between multimedia and print in terms of patient outcomes. Multimedia led to better outcomes vs. print in 21 (38%) comparisons vs. 5 (9%) instances for print. Regarding material development, 12 studies (40%) assessed readability and 5 (17%) involved patients in tool development. CONCLUSIONS: Multimedia appears to be a promising medium for patient education; however, the majority of studies found that print and multimedia performed equally well in practice. Few studies involved patients in material development, and less than half assessed the readability of materials. PRACTICE IMPLICATIONS: Future research should focus on comparing message-equivalent tools and assessing their effect on behavioral outcomes. Material development should include explicit attention to readability and patient input.

An EMR-based tool to support collaborative planning for medication use among adults with diabetes: design of a multi-site randomized control trial.

Patients with type II diabetes often struggle with self-care, including adhering to complex medication regimens and managing their blood glucose levels. Medication nonadherence in this population reflects many factors, including a gap between the demands of taking medication and the limited literacy and cognitive resources that many patients bring to this task. This gap is exacerbated by a lack of health system support, such as inadequate patient-provider collaboration. The goal of our project is to improve self-management of medications and related health outcomes by providing system support. The Medtable™ is an Electronic Medical Record (EMR)-integrated tool designed to support patient-provider collaboration needed for medication management. It helps providers and patients work together to create effective medication schedules that are easy to implement. We describe the development and initial evaluation of the tool, as well as the process of integrating it with an EMR system in general internal medicine clinics. A planned evaluation study will investigate whether an intervention centered on the Medtable™ improves medication knowledge, adherence, and health outcomes relative to a usual care control condition among type II diabetic patients struggling to manage multiple medications.

Usability of FDA-approved medication guides.

BACKGROUND: Medication guides are required documents to be distributed to patients in order to convey serious risks associated with certain prescribed medicines. Little is known about the effectiveness of this information to adequately inform patients on safe use. OBJECTIVE: To examine the readability, suitability, and comprehensibility of medication guides, particularly for those with limited literacy. DESIGN: Assessments of suitability and readability of 185 medication guides, and a sub-study examining change in suitability and readability from 2006 to 2010 among 32 of the medication guides (Study 1); 'open book' comprehension assessment of medication guides (Study 2). SETTING: Two general internal medicine clinics in Chicago, IL. PATIENTS: Four hundred and forty-nine adults seeking primary care services, ages 18-85. MEASUREMENTS: For Study 1, the Suitability Assessment of Materials (SAM) and Lexile score for readability. For Study 2, a tailored comprehension assessment of content found in three representative medication guides. RESULTS: The 185 analyzed medication guides were on average 1923 words (SD = 1022), with a mean reading level of 10-11th grade. Only one medication guide was deemed suitable in SAM analyses. None provided summaries or reviews, or framed the context first, while very few were rated as having made the purpose evident (8 %), or limited the scope of content (22 %). For Study 2, participants' comprehension of medication guides was poor (M = 52.7 % correct responses, SD = 22.6). In multivariable analysis, low and marginal literacy were independently associated with poorer understanding (ß = -14.3, 95 % CI -18.0 - -10.6, p < 0.001; low: ß = -23.7, 95 % CI -28.3 - -19.0, p < 0.001). CONCLUSION: Current medication guides are of little value to patients, as they are too complex and difficult to understand especially for individuals with limited literacy. Explicit guidance is offered for improving these print materials.

Literacy, cognitive function, and health: results of the LitCog study.

BACKGROUND: Emerging evidence suggests the relationship between health literacy and health outcomes could be explained by cognitive abilities. OBJECTIVE: To investigate to what degree cognitive skills explain associations between health literacy, performance on common health tasks, and functional health status. DESIGN: Two face-to-face, structured interviews spaced a week apart with three health literacy assessments and a comprehensive cognitive battery measuring 'fluid' abilities necessary to learn and apply new information, and 'crystallized' abilities such as background knowledge. SETTING: An academic general internal medicine practice and three federally qualified health centers in Chicago, Illinois. PATIENTS: Eight hundred and eighty-two English-speaking adults ages 55 to 74. MEASUREMENTS: Health literacy was measured using the Rapid Estimate of Adult Literacy in Medicine (REALM), Test of Functional Health Literacy in Adults (TOFHLA), and Newest Vital Sign (NVS). Performance on common health tasks were globally assessed and categorized as 1) comprehending print information, 2) recalling spoken information, 3) recalling multimedia information, 4) dosing and organizing medication, and 5) healthcare problem-solving. RESULTS: Health literacy measures were strongly correlated with fluid and crystallized cognitive abilities (range: r=0.57 to 0.77, all p<0.001). Lower health literacy and weaker fluid and crystallized abilities were associated with poorer performance on healthcare tasks. In multivariable analyses, the association between health literacy and task performance was substantially reduced once fluid and crystallized cognitive abilities were entered into models (without cognitive abilities: ß= -28.9, 95 % Confidence Interval (CI) -31.4 to -26.4, p; with cognitive abilities: ß= -8.5, 95 % CI -10.9 to -6.0). LIMITATIONS: Cross-sectional analyses, English-speaking, older adults only. CONCLUSIONS: The most common measures used in health literacy studies are detecting individual differences in cognitive abilities, which may predict one's capacity to engage in self-care and achieve desirable health outcomes. Future interventions should respond to all of the cognitive demands patients face in managing health, beyond reading and numeracy.

Literacy, cognitive ability, and the retention of health-related information about colorectal cancer screening.

Interventions to mitigate the impact of low literacy on patients' recall of information by simplifying language have had limited success. The current study examines the extent to which cognition explains the relationship between literacy and retention of health information. Primary care patients aged 40 to 85 years watched a video about colorectal cancer (CRC) screening and then answered knowledge-based questions about the video's content as well as a literacy assessment and cognitive assessments measuring processing speed, working memory, and-long term memory. A week later, available participants completed the knowledge assessment a second time. In regression models for immediate knowledge, literacy significantly predicted knowledge. However, once cognition (i.e., processing speed, working memory, and long-term memory) was added to the model, it explained 70.7% of the relationship between literacy and performance. A week later, literacy again significantly predicted knowledge, but entering cognition into the model explained 45.9% of the relationship between literacy and performance. These results suggest that cognition explains much of the association between literacy and both immediate and delayed recall of health information. Design and intervention strategies for educational tools should consider cognitive factors such as working memory demands in addition to focusing on the readability of materials.

Media and memory: the efficacy of video and print materials for promoting patient education about asthma.

OBJECTIVE: We examined the effects of presentation medium on immediate and delayed recall of information and assessed the effect of giving patients take-home materials after initial presentations. METHODS: Primary-care patients received video-based, print-based or no asthma education about asthma symptoms and triggers and then answered knowledge-based questions. Print participants and half the video participants received take-home print materials. A week later, available participants completed the knowledge assessment again. RESULTS: Participants receiving either intervention outperformed controls on immediate and delayed assessments (p<0.001). For symptom-related information, immediate performance did not significantly differ between print and video participants. A week later, receiving take-home print predicted better performance (p<0.05), as did self-reported review among recipients of take-home print (p<0.01). For content about inhaler usage, although video watchers outperformed print participants immediately after seeing the materials (p<0.001), a week later these two groups' performance did not significantly differ. Among participants given take-home materials, review predicted marginally better recall (p=0.06). CONCLUSION: Video and print interventions can promote recall of health-related information. Additionally, reviewable materials, if they are utilized, may improve retention. PRACTICE IMPLICATIONS: When creating educational tools, providers should consider how long information must be retained, its content, and the feasibility of providing tangible supporting materials.

Literacy and learning in health care.

The relationship between literacy and health outcomes are well documented in adult medicine, yet specific causal pathways are not entirely clear. Despite an incomplete understanding of the problem, numerous interventions have already been implemented with variable success. Many of those who proposed earlier strategies assumed the problem to originate from reading difficulties only. Given the timely need for more effective interventions, it is of increasing importance to reconsider the meaning of health literacy to advance our conceptual understanding of the problem and how best to respond. One potentially effective approach might involve recognizing the known associations between a larger set of cognitive and psychosocial abilities with functional literacy skills. Here we review the current health literacy definition and literature and draw on relevant research from the fields of education, cognitive science, and psychology. In this framework, a research agenda is proposed that considers an individual's "health-learning capacity," which refers to the broad constellation of cognitive and psychosocial skills from which patients or family members must draw to effectively promote, protect, and manage their own or a child's health. This new, related concept will lead, ideally, to more effective ways of thinking about health literacy interventions, including the design of health-education materials, instructional strategies, and the delivery of health care services to support patients and families across the life span.

Asthma 1-2-3: a low literacy multimedia tool to educate African American adults about asthma.

Asthma 1-2-3 is a newly-developed low-literacy multimedia education tool designed to promote asthma self-care concepts among African American adults. An expert panel (n = 10) informed content development for the tool. The video script and storyboard imagery were shown to 30 African Americans recruited from the American Lung Association, whose reactions and comments guided further revisions. The final version was pilot tested in three diverse community settings in Chicago to determine the efficacy of Asthma 1-2-3 at improving patient understanding of asthma and its symptoms. In all, 130 adults participated in the pilot test. Knowledge scores significantly improved from pretest to posttest following presentation of the developed tool for subjects across all literacy levels (Pretest: Mean = 4.2 [SD = 1.6]; Posttest: M = 6.8 [SD = 2.0], P < 0.001). Symptom pathophysiology concepts were the least understood. Individuals with low literacy had less total knowledge score gains compared to those with marginal and adequate literacy (1.8, 2.6, and 3.2 respectively; P = 0.002). The multimedia tool significantly improved understanding of asthma. Individuals with limited literacy may require additional instruction, repeated viewing, or added tangible cues (i.e. supplementary print materials) to support knowledge retention. In general, feedback from the target population was particularly helpful in the development of the tool and its initial evaluation, and should be considered as a necessary step in the creation of other patient education materials.

Working memory and the design of health materials: a cognitive factors perspective.

OBJECTIVE: Working memory and other supportive cognitive processes involved in learning are reviewed in the context of developing patient education materials. We specifically focus on the impact of certain design factors such as text format and syntax, the inclusion of images, and the choice of modality on individuals' ability to understand and remember health information. METHODS: A selective review of relevant cognitive and learning theories is discussed with regard to their potential impact on the optimal design of health materials. RESULTS: Working memory is measured as an individual's capacity to hold and manipulate information in active consciousness. It is limited by necessity, and well-designed health materials can effectively minimize extraneous cognitive demands placed on individuals, making working memory resources more available to better process content-related information. CONCLUSIONS: Further research is needed to evaluate specific design principles and identify ideal uses of print versus video-based forms of communication for conveying information. PRACTICE IMPLICATIONS: The process of developing health materials should account for the cognitive demands that extrinsic factors such as modality place on patients.

A case for clarity in the writing of health statements.

OBJECTIVE: While effectively written health-related materials can facilitate self-care, using negative wording may backfire, as patients may forget negations and remember the opposite of intended information. The present study attempts to determine if older readers are particularly susceptible to misremembering negatively worded health-related statements. METHODS: Younger and older adults read positively and negatively worded statements and were later tested for memory of the exact statements, statements opposite in meaning due to the addition or deletion of a negation, and entirely new statements. RESULTS: For intact statements, both groups recognized more positive than negative statements. When statements reversed meanings, younger adults were more likely to accurately recognize items that changed from negative to positive than were older adults, who were more likely to incorrectly endorse changed items as intact when items began negative and became positive than the reverse. CONCLUSION: The inclusion of negations, often used in attention-grabbing techniques such as myth-busting, can backfire, especially among older audiences who are less likely to accurately remember negatively worded items and especially likely to endorse their positive counterparts. PRACTICE IMPLICATIONS: Designers of healthcare materials should avoid using negatively worded statements, which may be misremembered by vulnerable populations, in favor of positive wording.