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Objectives Health literacy encompasses a broad skill set linked to patients' self-management ability and the complexity of their health care environments. Self-management in the context of multimorbidity is particularly challenging, placing patients at risk of poor clinical outcomes. This study aimed to explore the prognostic associations between health literacy domains, depression, and 12-month health care utilization and mortality in patients with diabetes and end-stage renal disease (DM-ESRD). Design Observational study. Methods Patients with DM-ESRD undergoing haemodialysis were recruited. Information on all-cause hospitalization/admission and mortality of participants was recorded. Negative binomial and Cox regressions were used to model risk factors for hospitalization and mortality. Results A total 221 participants [median age: 59 years, 61.6% men, 54.8% Chinese] were recruited. Differences in health literacy were found as a function of age, ethnicity, relationship status, and education. After adjusting for demographic and clinical factors, the HLQ domain Actively Managing My Health remained independently associated with lower rates of hospitalization (incidence rate ratio (IRR) = 0.674, 95% CI [0.490, 0.925], p = .02) and mortality (hazard ratio = 0.382, 95% CI [0.160, 0.848], p = .02). Cumulative hospitalization days were associated with employment status (IRR = 2.242, 95% CI [1.223, 4.113], p = .009), albumin (IRR = 0.918, 95% CI [0.854, 0.988], p = .02), HbA1c (IRR = 1.183, 95% CI [1.028, 1.360], p = .02), comorbidity burden (IRR = 1.137, 95% CI [1.003, 1.289], p = .04), and depression (IRR = 1.059, 95% CI [1.003, 1.118], p = .04) but no health literacy domains. Conclusions Health literacy skills related to Actively Managing My Health predict hospitalization and mortality independently of other risk factors. The HLQ provides an assessement of novel health literacy parameters which offer new insights into patients' status and behaviours and may strengthen interventions to improve clinical services, and patient outcomes in DM-ESRD. Statement of contribution What is already known on this subject? Patients with diabetes (DM) comprise the fastest growing segment of patients with end-stage renal disease (ESRD). Health literacy (HL) is pivotal for managing the complex treatment guidelines for DM-ESRD. Most prior work on HL focused on functional HL and shown significant associations with mortality and hospitalization. Limited research has investigated wider HL skills in relation to clinical outcomes. What does this study add? Supporting patients in Actively Managing my health liteacy skills is critical in decreasing probability of hospitalization and morbidity. The presence of symptoms of depression is associated with longer hospitalization period. [ABSTRACT FROM AUTHOR]

Background: The health literacy skills required by individuals to interact effectively with health services depends on the complexity of those services, and the demands they place on people. Public health and social service organisations have a responsibility to provide services and information in ways that promote equitable access and engagement, that are responsive to diverse needs and preferences, and support people to participate in decisions regarding their health and wellbeing. The aim of this study was to develop a conceptual framework describing the characteristics of health literacy responsive organisations.Methods: Concept mapping (CM) workshops with six groups of professionals (total N = 42) from across health and social services sectors were undertaken. An online concept mapping consultation with 153 professionals was also conducted. In these CM activities, participants responded to the seeding statement "Thinking broadly from your experiences of working in the health system, what does an organisation need to have or do in order to enable communities and community members to fully engage with information and services to promote and maintain health and wellbeing". The CM data were analysed using multidimensional scaling and hierarchical cluster analyses to derive concept maps and cluster tree diagrams. Clusters from the CM processes were then integrated by identifying themes and subthemes across tree diagrams.Results: Across the workshops, 373 statements were generated in response to the seeding statement. An additional 1206 statements were generated in the online consultation. 84 clusters were derived within the workshops and 20 from the online consultation. Seven domains of health literacy responsiveness were identified; i) External policy and funding environment; ii) Leadership and culture; iii) Systems, processes and policies; iv) Access to services and programs; v) Community engagement and partnerships; vi) Communication practices and standards; and vii) Workforce. Each domain included 1 to 5 sub-domains (24 sub-domains in total).Conclusions: Using participatory research processes, a conceptual framework describing the characteristics, values, practices and capabilities of organisational health literacy responsiveness was derived. The framework may guide the planning and monitoring of health service and health system improvements, and has the potential to guide effective public health policy and health system reforms. [ABSTRACT FROM AUTHOR]

Background: The Health Literacy Questionnaire (HLQ) has nine scales that each measure an aspect of the multidimensional construct of health literacy. All scales have good psychometric properties. However, it is the interpretations of data within contexts that must be proven valid, not just the psychometric properties of a measurement instrument. The purpose of this study was to establish the extent of concordance and discordance between individual patient and clinician interpretations of HLQ data in the context of complex case management.Methods: Sixteen patients with complex needs completed the HLQ and were interviewed to discuss the reasons for their answers. Also, the clinicians of each of these patients completed the HLQ about their patient, and were interviewed to discuss the reasons for their answers. Thematic analysis of HLQ scores and interview data determined the extent of concordance between patient and clinician HLQ responses, and the reasons for discordance.Results: Highest concordance (80%) between patient and clinician item-response pairs was seen in Scale 1 and highest discordance (56%) was seen in Scale 6. Four themes were identified to explain discordance: 1) Technical or literal meaning of specific words; 2) Patients' changing or evolving circumstances; 3) Different expectations and criteria for assigning HLQ scores; and 4) Different perspectives about a patient's reliance on healthcare providers.Conclusion: This study shows that the HLQ can act as an adjunct to clinical practice to help clinicians understand a patient's health literacy challenges and strengths early in a clinical encounter. Importantly, clinicians can use the HLQ to detect differences between their own perspectives about a patient's health literacy and the patient's perspective, and to initiate discussion to explore this. Provision of training to better detect these differences may assist clinicians to provide improved care. The outcomes of this study contribute to the growing body of international validation evidence about the use of the HLQ in different contexts. More specifically, this study has shown that the HLQ has measurement veracity at the patient and clinician level and may support clinicians to understand patients' health literacy and enable a deeper engagement with healthcare services. [ABSTRACT FROM AUTHOR]

Background: The need for healthcare strengthening to enhance equity is critical, requiring systematic approaches that focus on those experiencing lesser access and outcomes. This project developed and tested the Ophelia (OPtimising HEalth LIteracy and Access) approach for co-design of interventions to improve health literacy and equity of access. Eight principles guided this development: Outcomes focused; Equity driven, Needs diagnosis, Co-design, Driven by local wisdom, Sustainable, Responsive and Systematically applied. We report the application of the Ophelia process where proof-of-concept was defined as successful application of the principles.Methods: Nine sites were briefed on the aims of the project around health literacy, co-design and quality improvement. The sites were rural/metropolitan, small/large hospitals, community health centres or municipalities. Each site identified their own priorities for improvement; collected health literacy data using the Health Literacy Questionnaire (HLQ) within the identified priority groups; engaged staff in co-design workshops to generate ideas for improvement; developed program-logic models; and implemented their projects using Plan-Do-Study-Act (PDSA) cycles. Evaluation included assessment of impacts on organisations, practitioners and service users, and whether the principles were applied.Results: Sites undertook co-design workshops involving discussion of service user needs informed by HLQ (n = 813) and interview data. Sites generated between 21 and 78 intervention ideas and then planned their selected interventions through program-logic models. Sites successfully implemented interventions and refined them progressively with PDSA cycles. Interventions generally involved one of four pathways: development of clinician skills and resources for health literacy, engagement of community volunteers to disseminate health promotion messages, direct impact on consumers' health literacy, and redesign of existing services. Evidence of application of the principles was found in all sites.Conclusions: The Ophelia approach guided identification of health literacy issues at each participating site and the development and implementation of locally appropriate solutions. The eight principles provided a framework that allowed flexible application of the Ophelia approach and generation of a diverse set of interventions. Changes were observed at organisational, staff, and community member levels. The Ophelia approach can be used to generate health service improvements that enhance health outcomes and address inequity of access to healthcare. [ABSTRACT FROM AUTHOR]

Background: Health literacy is simply defined as an individual's ability to access, understand and use information in ways that promote and maintain good health. Lower health literacy has been found to be associated with increased emergency department presentations and potentially avoidable hospitalisations. This study aimed to determine the health literacy of hospital inpatients, and to examine if associations exist between different dimensions of their health literacy, sociodemographic characteristics and hospital services use.Methods: A written survey was sent to 3,252 people aged ≥18 years in English, Arabic, Chinese, Vietnamese, Italian or Greek. The survey included demographic and health questions, and the Health Literacy Questionnaire (HLQ). The HLQ is a multidimensional instrument comprising nine independent scales. Use of hospital services was measured by length of stay, number of admissions in 12 months and number of emergency department presentations. Effect size (ES) for standardised differences in means described the magnitude of differences in HLQ scale scores between demographic and socioeconomic groups.Results: 385 questionnaires were returned (13%); mean age 64 years (SD 17), 49% female. Aged ≥65 years (55%), using the Internet < once a month (37%), failure to complete high school (67%), low household income (39%), receiving means-tested government benefits (61%) and being from a culturally and linguistically diverse (CALD) background (24%), were all associated with lower scores in some health literacy scales. Being aged ≥65 years, not currently employed, receiving government benefits, and being from a CALD background were also associated with increased use of some hospital services. There was no association between lower scores on any HLQ scale and greater use of hospital services.Conclusion: We found no association between lower health literacy and greater use of hospital health services. However increased age, having a CALD background and not speaking English at home were all associated with having the most health literacy challenges Strategies to address these are needed to reduce health inequalities. [ABSTRACT FROM AUTHOR]

Background and objective: The Internet is increasingly prominent as a source of health information for people with multiple sclerosis (MS). But there has been little exploration of the needs, experiences and preferences of people with MS for integrating treatment information into decision making, in the context of searching on the Internet. This was the aim of our study. Design: Sixty participants (51 people with MS; nine family members) took part in a focus group or online forum. They were asked to describe how they find and assess reliable treatment information (particularly online) and how this changes over time. Thematic analysis was underpinned by a coding frame. Results: Participants described that there was both too much information online and too little that applied to them. They spoke of wariness and scepticism but also empowerment. The availability of up ‐ to ‐ date and unbiased treatment information, including practical and lifestyle ‐ related information, was important to many. Many participants were keen to engage in a ‘research partnership’ with health professionals and developed a range of strategies to enhance the trustworthiness of online information. We use the term ‘self ‐ regulation’ to capture the variations in information seeking behaviour that participants described over time, as they responded to their changing information needs, their emotional state and growing expertise about MS. Conclusions: People with MS have developed a number of strategies to both find and integrate treatment information from a range of sources. Their reflections informed the development of an evidence ‐ based consumer web site based on summaries of MS Cochrane reviews. [ABSTRACT FROM AUTHOR]

Background: Relatively little is known about the social distribution of total knee joint replacement (TKR) uptake in Australia. We examine associations between socioeconomic status (SES) and TKR performed for diagnosed osteoarthritis 2003–10 for all Australian males and females aged ≥30 yr. Methods: Data of primary TKR (n = 213,018, 57.4% female) were ascertained from a comprehensive national joint replacement registry. Residential addresses were matched to Australian Census data to identify area-level social disadvantage, and categorised into deciles. Estimated TKR rates were calculated. Poisson regression was used to model the relative risk (RR) of age-adjusted TKR per 1,000py, stratified by sex and SES. Results: A negative relationship was observed between TKR rates and SES deciles. Females had a greater rate of TKR than males. Surgery utilisation was greatest for all adults aged 70-79 yr. In that age group differences in estimated TKR per 1,000py between deciles were greater for 2010 than 2003 (females: 2010 RR 4.32 and 2003 RR 3.67; males: 2010 RR 2.04 and 2003 RR 1.78). Conclusions: Identifying factors associated with TKR utilisation and SES may enhance resource planning and promote surgery utilisation for end-stage osteoarthritis. [ABSTRACT FROM AUTHOR]

Background Several measurement tools have been developed to measure health literacy. The tools vary in their approach and design, but few have focused on comprehensive health literacy in populations. This paper describes the design and development of the European Health Literacy Questionnaire (HLS-EU-Q), an innovative, comprehensive tool to measure health literacy in populations. Method Based on a conceptual model and definition, the process involved item development, pre-testing, field-testing, external consultation, plain language check, and translation from English to Bulgarian, Dutch, German, Greek, Polish, and Spanish. Results The development process resulted in the HLS-EU-Q, which entailed two sections, a core health literacy section and a section on determinants and outcomes associated to health literacy. The health literacy section included 47 items addressing self-reported difficulties in accessing, understanding, appraising and applying information in tasks concerning decisions making in healthcare, disease prevention, and health promotion. The second section included items related to, health behaviour, health status, health service use, community participation, socio-demographic and socio-economic factors. Conclusion By illuminating the detailed steps in the design and development process of the HLS-EU-Q, it is the aim to provide a deeper understanding of its purpose, its capability and its limitations for others using the tool. By stimulating a wide application it is the vision that HLS-EU-Q will be validated in more countries to enhance the understanding of health literacy in different populations. [ABSTRACT FROM AUTHOR]

There is strong rationale for improving care for people with chronic conditions, including osteoarthritis (OA). Successful implementation of healthcare reform requires new concepts and directions that are strongly supported by policy, new models of care (service redesign) and changes in day-to-day practice (healthcare provider and patient practice). In this paper we discuss the extent to which policy about management of OA of the hip and knee has been translated into new service models in Australia. A structured search of government and other key health websites in Australia was performed to identify policy, funding initiatives and new services models for managing OA of the hip and knee. This search was supported by a literature review. Musculoskeletal conditions were designated a National Health Priority in Australia in 2002. Under the Better Arthritis and Osteoporosis Care initiative, Australia has developed a national policy for OA care and national evidence-based clinical practice guidelines for management of OA of the hip and knee. Only two well-described examples of new chronic disease management service models, the Osteoarthritis Clinical Pathway (OACP) model and the Osteoarthritis Hip and Knee Service (OAHKS) were identified. Primarily focused within acute care public hospital settings, these have been shown to be feasible and acceptable but have limited data on clinical impact and cost-effectiveness. While policy is extant, implementation has not been systematic and comprehensive. Clinicians have evidence-based recommendations for OA management but are poorly supported by service models to deliver these effectively and efficiently. [ABSTRACT FROM AUTHOR]

The integration of routine clinical administrative activities into ongoing rigorous clinical research poses challenges for both clinicians and researchers. This case study describes the development of a responsive database system used to facilitate comprehensive longitudinal research into the outcomes of patients waiting for hip and knee replacement surgery in a large public teaching hospital. The initial research procedure was paper-based, with manual patient matching and data entry. This process was time-consuming and associated with substantial risk of error and omissions, necessitating the design of a better system. An integrated database system was designed to receive daily electronic updates of the orthopaedic waiting-list and scheduled clinic and surgery dates. Using readily available software (Microsoft Access), new patients were identified through specifying inclusion and exclusion criteria which allowed rapid and complete recruitment at time of entry to the waiting-list. The integrated system specified the appropriate timing of multiple follow-up assessments, provided prompt information on recruitment for reporting purposes and integrated multiple linked research projects within one database. Seamless exporting of data to statistical programs for analysis was also enabled. This simple integrated approach facilitated efficient execution of a longitudinal study from recruitment to statistical analysis while maximising confidentiality and minimising resources required. This case study describes the development and design of a simple system which could be easily adapted for database management in hospital or clinic-based settings according to local requirements. [ABSTRACT FROM AUTHOR]

Measurement of Health-Related Quality of Life (HRQoL) of the elderly requires instruments with demonstrated sensitivity, reliability, and validity, particularly with the increasing proportion of older people entering the health care system. This article reports the psychometric properties of the 12-item Assessment of Quality of Life (AQoL) instrument in chronically ill community-dwelling elderly people with an 18-month follow-up. Comparator instruments included the SF-36 and the OARS. Construct validity of the AQoL was strong when examined via factor analysis and convergent and divergent validity against other scales. Receiver Operator Characteristic (ROC) curve analyses and relative efficiency estimates indicated the AQoL is sensitive, responsive, and had the strongest predicative validity for nursing home entry. It was also sensitive to economic prediction over the follow-up. Given these robust psychometric properties and the brevity of the scale, AQoL appears to be a suitable instrument for epidemiologic studies where HRQoL and utility data are required from elderly populations. [Copyright &y& Elsevier]

The article discusses the role of self-management support and programs for people with arthritis and other chronic diseases. It states that self-management support is the facility that health care and social-care services offer to make individuals take better care of themselves. It mentions that for arthritis, the prevailing approach to self-management support has been the implementation of community-based group programs.

Abstract: Objective: Health literacy refers to an individual's ability to seek, understand, and use health information. This paper describes the development and psychometric testing of the Health Literacy Management Scale (HeLMS). Methods: Content areas were identified from a conceptual framework derived from interviews and concept mapping. Items were generated from statements from concept mapping participants. Construction (N =333) and replication (N =350) samples were participants in chronic disease self-management programs and emergency department attendees. Factor analysis was used to refine constructs and define psychometric properties. Results: Consultations generated 8 scales each with 4–5 items: Understanding health information, Accessing GP healthcare services, Communication with health professionals, Being proactive and Using health information, Patient attitudes towards their health, Social support, and Socioeconomic considerations. Confirmatory factor analyses indicated good fit of the data with the model (RMSEA=0.07, SRMR=0.05, CFI=0.97) and all domains had high internal consistency (Cronbach alpha>0.82). Conclusion: The HeLMS has acceptable psychometric properties and assesses a range of health literacy constructs important to patients when seeking, understanding and using health information within the healthcare system. Practice implications: The HeLMS presents a new approach to assessing health literacy in healthcare settings. [Copyright &y& Elsevier]

Abstract: Objective: To quantify the benefits that people receive from participating in self-management courses and identify subgroups that benefit most. Methods: People with a wide range of chronic conditions attending self-management courses (N =1341 individuals) were administered the Health Education Impact Questionnaire (heiQ). Baseline and follow-up data were collected resulting in 842 complete responses. Outcomes were categorized as substantial improvement (effect size, ES≥0.5), minimal/no change (ES −0.49 to 0.49) and substantial decline (ES≤−0.5). Results: On average, one third of participants reported substantial benefits at the end of a course and this ranged from 49% in the heiQ subscale Skill and technique acquisition to 27% in the heiQ subscale Health service navigation. Stratification by gender, age and education showed that younger participants were more likely to benefit, particularly young women. No further subgroup differences were observed. Conclusion: While the well-being of people with chronic diseases tends to decline, about one third of participants from a wide range of backgrounds show substantial improvements in a range of skills that enable them to self-manage. Practice implications: These data support the application of self-management courses indicating that they are a useful adjunct to usual care for a modest proportion of attendees. [Copyright &y& Elsevier]

Abstract: Objectives: To describe an alternate approach for the calculation of sensitivity and specificity when analyzing the accuracy of screening tools, which can be used when standard calculations may be inappropriate. SensitivityER (ER denoting event rate) is the number of events correctly predicted, divided by the total number of events. SpecificityER is the amount of time that study participants are predicted to be event negative, divided by the total amount of participant observed time. Variance estimates for these statistics are constructed by bootstrap resampling, taking into account event dependence. Methods: Standard and alternate approaches for calculating sensitivity and specificity were applied to hospital falls risk screening tool data. In this application, the outcome of interest was a recurrent event, there were multiple applications of the screening tool, delays in screening tool completion, and patients'' follow-up durations were unequal. Results: Application of sensitivityER and specificityER to this data not only provided a clearer description of the screening tool''s overall accuracy, but also allowed examination of accuracy over time, accuracy in predicting specific event numbers, and evaluation of the added value that screening tool reapplications may have. Conclusion: SensitivityER and specificityER provide a valuable approach to screening tool evaluation in the clinical setting. [Copyright &y& Elsevier]