Person:

Rudd, Rima

Background: Local public health nurses (PHNs) have been recognized as the main health service providers in communities in Japan. The Fukushima nuclear disaster in 2011 has, however, created a major challenge for them in responding to mothers’ concerns. This was in part due to difficulties in assessing, understanding and communicating health risks on low-dose radiation exposure. In order to guide the development of risk communication plans, this study sought to investigate mothers’ primary concerns and possible solutions perceived by a core healthcare profession like the PHNs. Methods: A total of 150 records from parenting counseling sessions conducted between PHNs and mothers who have attended mandatory 18-month health checkups for their children at the Fukushima City Health and Welfare Center in 2010, 2011 (year of disaster) and 2012 were examined. Discussion notes of three peer discussions among PHNs organized in response to the nuclear disaster in 2012 and 2013 were also analyzed. All transcribed data were first subjected to text mining to list the words according to their frequencies and inter-relationships. The Steps Coding and Theorization method was then undertaken as a framework for qualitative analysis. Results: PHNs noted mothers to have considerable needs for information on radiation risks as they impact on decisions related to relocations, concerns for child safety, and experiences with interpersonal conflicts within the family owing to differing risk perceptions. PHNs identified themselves as the information channels in the community, recommended the building of their risk communication capacities to support residents in making well-informed decisions, and advocated for self-measurement of radiation levels to increase residents’ sense of control. PHNs also suggested a more standardized form of information dissemination and an expansion of community-based counseling services. Conclusions: Inadequate risk communication on radiation in the Fukushima nuclear incident has resulted in multiple repercussions for mothers in the community. Empowerment of local residents to assume more active roles in the understanding of their environment, increasing PHNs’ capacity in communication, and an expansion of health services such as counseling will together better address risk communication challenges in post-disaster recovery efforts.

Self-report of musculoskeletal conditions is often used to estimate population prevalence and to determine disease burden and influence policy. However, self-report of certain musculoskeletal conditions is frequently inaccurate, suggesting inadequate communication to the patient of their diagnosis. The aim of this study is to determine the association between functional health literacy (FHL) and self-reported musculoskeletal conditions in a representative population survey. FHL was measured using Newest Vital Sign in 2824 randomly selected adults. Participants also self-reported medically diagnosed arthritis, gout, and osteoporosis. Multiple logistic regression was adjusted for age and sex. The prevalence of self-reported arthritis, gout, and osteoporosis was 25.2%, 4.9%, and 5.6%, respectively. The prevalence of those at risk for inadequate FHL was 24.0% and high likelihood of inadequate FHL was 21.0%. However, over 50% of respondents with arthritis or gout had at risk/inadequate FHL, increasing to 70% of those self-reporting osteoporosis. After adjustment for age and sex, respondents in the arthritis subgroup of “don't know” and self-reported osteoporosis were significantly more likely to have inadequate FHL than the general population. This study indicates a substantial burden of low health literacy amongst people with musculoskeletal disease. This has implications for provider-patient communication, individual healthcare, population estimates of musculoskeletal disease, and impact of public health messages.

A mismatch between the literacy skills of individuals and the demands of oral health services may erect an unnecessary barrier to preventive care and treatment. Findings from the 1992 survey of adult literacy in the United States indicate that more than two-thirds of adults over the age of sixty were limited in their ability to use written health materials in prose format, had problems finding and processing quantitative information, and were very limited in their ability to use documents such as forms, lists, charts, and graphs. Thus, many older adults face barriers to oral care, to needed information, to full participation in decision making and informed consent, and for follow-up activities. The pathways between literacy and health outcomes are being examined, and the body of literature linking literacy to health continues to grow. However, similar studies examining literacy and oral health outcomes have not yet been undertaken. Research in this area might well begin with consideration of the skills needed to perform important oral health tasks. Rigorous studies of the impact of improved communication strategies on elders’ access to care, participation in services, and action steps would lend insight into needed change.

Most health literacy research to date has assessed health literacy using either general reading tests or text-based appraisals of reading and numeracy skills, yet the definition of health literacy includes domains beyond reading ability. Effective oral communication between doctor and patient is an important component of health literacy, but only recently have efforts been made to develop measures that tap into domains beyond those that can be assessed with text-based measures. Focusing on oral exchange, this paper describes computer-assisted approaches to quantifying word use and the development of three word-use measures that can be used to study health literacy in transcripts of clinical encounters. The measures can be used to assess either the expressed literacy level of patients or the aural literacy demands made by doctors. Importantly, the computer-assisted quantitative measures described here make it possible for word use to be analyzed at a level of detail that human raters would be hard pressed to attain.

Objective

Randomized controlled trials in patient education often have difficulty enrolling vulnerable populations – specifically, older, poorer and less educated individuals. We undertook a randomized controlled trial (RCT) of an educational intervention for arthritis management, which included strategies to remove literacy-related barriers to participation. This paper reports on the multi-stage recruitment process and assesses whether refusal to participate was related to education, age, gender, working status or insurance status.

Methods

The recruitment protocol was designed to eliminate literacy-related barriers to participation. Patients were never asked to read or fill out forms. Interactions were oral, using everyday terms and short, clear sentences. Patients who declined during a screening call were considered Stage 1 Refusers. Patients who initially expressed interest but neither completed a baseline questionnaire nor provided consent were considered Stage 2 Refusers. Patients who consented were considered Enrollees. Age, gender, and insurance status were compared between Stage 1 Refusers and Enrollees. A second analysis compared these variables, plus educational attainment and working status, between Stage 2 Refusers and Enrollees.

Results

Of 408 eligible patients, there were 193 (47.3%) Stage 1 Refusers, 81 (19.9%) Stage 2 Refusers and 134 (32.8%) Enrollees. A higher proportion of Stage 1 Refusers than Enrollees were ≥65 years old (58% vs. 37%, p=.0003). Multivariate analysis, adjusting for gender and insurance status, confirmed the effect of older age on refusal (OR=2.3 (1.4, 3.6)). There were no significant differences between Stage 2 Refusers and Enrollees.

Conclusion

We found no evidence of refusal to participate due to educational attainment, working status, insurance status, or gender. Older patients were more likely to refuse participation at the first stage of recruitment.

Practice Implications

Researchers should continue efforts to increase participation among older patients, particularly when studies are designed to be generalized to an elderly population as is the case with arthritis research. Strategies used in this recruitment protocol designed to remove literacy-related barriers to recruitment may be responsible for the observation that subjects with lower education did not have lower refusal rates. Such strategies deserve further study.

Objective

Test the efficacy of educational interventions to reduce literacy barriers and enhance health outcomes among patients with inflammatory arthritis.

Methods

The intervention consisted of plain language information materials and/or two individualized sessions with an arthritis educator. Randomization was stratified by education level. Principal outcomes included adherence to treatments, self-efficacy, satisfaction with care, and appointment keeping. Secondary outcomes included health status and mental health. Data were collected at baseline, six, and twelve months post.

Results

Of the 127 patients, half had education beyond high school and three quarters had disease duration greater than five years. There were no differences in the primary outcome measures between the groups. In mixed models controlling for baseline score and demographic factors, the intervention group showed improvement in mental health score at six and twelve months (3.0 and 3.7 points, respectively), while the control group showed diminished scores (−4.5 and −2.6 points, respectively) (p=0.03 and 0.01).

Conclusion

While the intervention appears to have had no effect on primary outcomes, further studies with continued attention to literacy are warranted. Study site and disease duration must be considered as participants in this study had higher than average health literacy and had established diagnoses for years prior to this study.

Practice Implications

The study offers insight into an application of many of the protocols currently recommended to ameliorate effects of limited literacy.

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 the 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 in order 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. We review the current health literacy definition and literature and draw upon 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, referring to the broad constellation of cognitive and psychosocial skills patients or family members must draw upon to effectively promote, protect, and manage their own or a child's health. This new, related concept will ideally lead to more effective ways of thinking about health literacy interventions, including the design of health education materials, instructional strategies, and the delivery of healthcare services to support patients and families across the lifespan.

Objective  Doctors often use medical language with their patients despite findings from a variety of studies that have shown that patients frequently misunderstand medical terminology. Little is known about the patterns of medical word use by doctors and patients during clinical encounters.

Methods  A content analysis of 16 verbatim transcripts of first clinical encounters between rheumatologists and newly referred patients was conducted to assess how doctors and patients introduced medical words. Medical words were identified via a computer program using a defined list.

Results  Doctors did not introduce or use more medical words than patients, but the types of words that doctors and patients introduced did differ. The majority of patient‐initiated medical words occurred during the history taking (94%). Doctors did not explain, or use as part of an explanation, the majority (79%) of the medical words they introduced, and patients seldom responded in a way that would indicate whether or not they had correctly interpreted those terms. There was relatively little repetition of medical words within or even across encounters.

Conclusions  This study provides insights into how the use of medical terminology could contribute to misunderstanding. Findings suggest that steps already promoted in the literature to improve doctor–patient communication may also ameliorate potential problems arising from the use of medical terminology.

Background

Individual home characteristics have been associated with indoor allergen exposure; however, the influence of neighborhood-level characteristics has not been well-studied. We defined neighborhoods as community districts determined by the New York Department of City Planning.

Objective

We examined the relationship between neighborhood-level characteristics and the presence of dust mite (Der f 1), cat (Fel d 1), cockroach (Bla g 2), and mouse (MUP) allergens in the household.

Methods

Using data from the Puerto Rican Asthma Project, a birth cohort of Puerto Rican children at risk of allergic sensitization (n=261) we examined associations between neighborhood characteristics (percent tree canopy, asthma hospitalizations per 1000 children, roadway length within 100 meters of buildings, serious housing code violations per 1000 rental units, poverty rates, and felony crime rates) and the presence of indoor allergens. Allergen cutpoints were used for categorical analyses and defined as follows: dust mite: >0.25 μg/g; cat: >1 μg/g; cockroach: >1 U/g; mouse: >1.6 μg/g.

Results

Serious housing code violations were statistically significantly positively associated with dust mite, cat and mouse allergens (continuous variables), adjusting for mother's income and education, and all neighborhood-level characteristics. In multivariable logistic regression analyses, medium levels of housing code violations were associated with higher dust mite and cat allergens (1.81, 95%CI: 1.08, 3.03 and 3.10, 95%CI: 1.22, 7.92, respectively). A high level of serious housing code violations was associated with higher mouse allergen (2.04, 95%CI: 1.15, 3.62). A medium level of housing code violations was associated with higher cockroach allergen (3.30, 95%CI: 1.11, 9.78).

Conclusions

Neighborhood-level characteristics, specifically housing code violations, appear to be related to indoor allergens, which may have implications for future research explorations and policy decisions.