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Using data from the Louisiana Department of Public Health, we explored the spatial relationships between the Social Vulnerability Index (SVI) and COVID-19-related vaccination and mortality rates. Publicly available COVID-19 vaccination and mortality data accrued from December 2020 to October 2021 was downloaded from the Louisiana Department of Health website and merged with the SVI data; geospatial analysis was then performed to identify the spatial association between the SVI and vaccine uptake and mortality rate. Bivariate Moran’s I analysis revealed significant clustering of high SVI ranking with low COVID-19 vaccination rates (1.00, p p

Background As health systems transition to value-based care, improving transitional care (TC) remains a priority. Hospitals implementing evidence-based TC models often adapt them to local contexts. However, limited research has evaluated which groups of TC strategies, or transitional care activities, commonly implemented by hospitals correspond with improved patient outcomes. In order to identify TC strategy groups for evaluation, we applied a data-driven approach informed by literature review and expert opinion. Methods Based on a review of evidence-based TC models and the literature, focus groups with patients and family caregivers identifying what matters most to them during care transitions, and expert review, the Project ACHIEVE team identified 22 TC strategies to evaluate. Patient exposure to TC strategies was measured through a hospital survey (N = 42) and prospective survey of patients discharged from those hospitals (N = 8080). To define groups of TC strategies for evaluation, we performed a multistep process including: using ACHIEVE’S prior retrospective analysis; performing exploratory factor analysis, latent class analysis, and finite mixture model analysis on hospital and patient survey data; and confirming results through expert review. Machine learning (e.g., random forest) was performed using patient claims data to explore the predictive influence of individual strategies, strategy groups, and key covariates on 30-day hospital readmissions. Results The methodological approach identified five groups of TC strategies that were commonly delivered as a bundle by hospitals: 1) Patient Communication and Care Management, 2) Hospital-Based Trust, Plain Language, and Coordination, 3) Home-Based Trust, Plain language, and Coordination, 4) Patient/Family Caregiver Assessment and Information Exchange Among Providers, and 5) Assessment and Teach Back. Each TC strategy group comprises three to six, non-mutually exclusive TC strategies (i.e., some strategies are in multiple TC strategy groups). Results from random forest analyses revealed that TC strategies patients reported receiving were more important in predicting readmissions than TC strategies that hospitals reported delivering, and that other key co-variates, such as patient comorbidities, were the most important variables. Conclusion Sophisticated statistical tools can help identify underlying patterns of hospitals’ TC efforts. Using such tools, this study identified five groups of TC strategies that have potential to improve patient outcomes.

BACKGROUND: Evidence of the effectiveness of treatment for obesity delivered in primary care settings in underserved populations is lacking. METHODS: We conducted a cluster-randomized trial to test the effectiveness of a high-intensity, lifestyle-based program for obesity treatment delivered in primary care clinics in which a high percentage of the patients were from low-income populations. We randomly assigned 18 clinics to provide patients with either an intensive lifestyle intervention, which focused on reduced caloric intake and increased physical activity, or usual care. Patients in the intensive-lifestyle group participated in a high-intensity program delivered by health coaches embedded in the clinics. The program consisted of weekly sessions for the first 6 months, followed by monthly sessions for the remaining 18 months. Patients in the usual-care group received standard care from their primary care team. The primary outcome was the percent change from baseline in body weight at 24 months. RESULTS: All 18 clinics (9 assigned to the intensive program and 9 assigned to usual care) completed 24 months of participation; a median of 40.5 patients were enrolled at each clinic. A total of 803 adults with obesity were enrolled: 452 were assigned to the intensive-lifestyle group, and 351 were assigned to the usual-care group; 67.2% of the patients were Black, and 65.5% had an annual household income of less than $40,000. Of the enrolled patients, 83.4% completed the 24-month trial. The percent weight loss at 24 months was significantly greater in the intensive-lifestyle group (change in body weight, −4.99%; 95% confidence interval [CI], −6.02 to −3.96) than in the usual-care group (−0.48%; 95% CI, −1.57 to 0.61), with a mean between-group difference of −4.51 percentage points (95% CI, −5.93 to −3.10) (P

We examined knowledge of Alzheimer’s disease and related dementias (ADRD), resources, and research opportunities among older African American (AA) and Caucasian caregivers. A mixed methods design integrated qualitative (focus group) and quantitative (survey) data from Northwest Louisiana. Eight focus groups (59 adults, 92% female, 78% AA, 25% rural) revealed limited knowledge. Quantitative findings from 117 ADRD caregivers (83% female, 72% AA, 30% limited heath literacy, 27% low income) indicated participants obtained information from providers (54%), friends and relatives (32%), and the internet (37%). Barriers to care were cost (24%) and lack of family agreement (17%). Few families used adult daycare (8%) or support groups (28%). Concerns about research participation were violation of privacy (30%) and fear of patient distress (27%). Distrust of doctors was minimal (3%). Findings did not vary by race. There is a need for clear, literacy-appropriate information about ADRD, caregiver resources, and clinical trials.

Background: Low health literacy is associated with poor health outcomes in many chronic diseases and may have an important role in determining surgical outcomes. This study aims to comprehensively review the current state of science on adult health literacy in surgery and to identify knowledge gaps for future research. Methods: Using the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines, a systematic search was conducted to identify all studies from January 2002 through May 2018 that used validated instruments to assess health literacy among adult patients undergoing surgery. Studies were assessed for quality using the Newcastle-Ottawa scale and evaluated on findings by their focus on identifying health literacy levels, understanding associations with surgical outcomes, and/or developing interventions to address low health literacy. Key Results: There were 51 studies on health literacy with data from 22,139 patients included in this review. Low health literacy was present in more than one-third of surgical patients (34%, interquartile range 16%–50%). The most commonly used validated instrument for assessment of health literacy in the surgical population was the Newest Vital Sign. Most studies were focused on identifying the prevalence of low health literacy within a surgery population (84%, n = 43). Few studies focused on understanding the association of health literacy to surgical outcomes (12%, n = 6) and even fewer studies developed interventions to address health literacy (4%, n = 2). Discussion: Low health literacy is common among surgical patients. Important opportunities exist to better understand the role of health literacy in determining surgical outcomes and to develop more health literacy-sensitive models of surgical care. [ HLRP: Health Literacy Research and Practice . 2020;4(1):e45–e65.] Plain Language Summary: Health literacy has not been well-studied in surgery but likely plays an important role. In this article, we reviewed all current research on health literacy in surgery to help us understand where we are at and where we need to go. We found that low health literacy is common and we need more ways to address it in surgery.

Most health literacy measures require in-person administration or rely upon self-report.We sought to develop and test the feasibility of a brief, objective health literacy measure that could be deployed via text messaging or online survey.Participants were recruited from ongoing NIH studies to complete a phone interview and online survey to test candidate items. Psychometric analyses included parallel analysis for dimensionality and item response theory. After 9 months, participants were randomized to receive the final instrument via text messaging or online survey.Three hundred six English and Spanish-speaking adults with ≥ 1 chronic condition MAIN MEASURES: Thirty-three candidate items for the new measure and patient-reported physical function, anxiety, depression, and medication adherence. All participants previously completed the Newest Vital Sign (NVS) in parent NIH studies.Participants were older (average 67 years), 69.6% were female, 44.3% were low income, and 22.0% had a high school level of education or less. Candidate items loaded onto a single factor (RMSEA: 0.04, CFI: 0.99, TLI: 0.98, all loadings.59). Six items were chosen for the final measure, named the HL6. Items demonstrated acceptable internal consistency (α=0.73) and did not display differential item functioning by language. Higher HL6 scores were significantly associated with greater educational attainment (r=0.41), higher NVS scores (r=0.55), greater physical functioning (r=0.26), fewer depressive symptoms (r=-0.20), fewer anxiety symptoms (r=-0.15), and fewer barriers to medication adherence (r=-0.30; all p.01). In feasibility testing, 75.2% of participants in the text messaging arm completed the HL6 versus 66.2% in the online survey arm (p=0.09). Socioeconomic disparities in completion were more common in the online survey arm.The HL6 demonstrates adequate reliability and validity in both English and Spanish. This performance-based assessment can be administered remotely using commonly available technologies with fewer logistical challenges than assessments requiring in-person administration.

Examine COVID-19 knowledge, concerns, behaviors, stress, and sources of information among patients in a safety-net health system in Louisiana. Research assistants surveyed participants via structured telephone interviews from April to October 2020. The data presented in this study were obtained in the pre-vaccine availability period. Of 623 adult participants, 73.5% were female, 54.7% Black, and 44.8% lived in rural small towns; mean age was 48.69. Half (50.5%) had spoken to a healthcare provider about the virus, 25.8% had been tested for COVID-19; 11.4% tested positive. Small town residents were less likely to be tested than those in cities (21.1% vs 29.3%, p = 0.05). Knowledge of COVID-19 symptoms and ways to prevent the disease increased from (87.9% in the spring to 98.9% in the fall, p

Purpose The majority of colorectal cancer (CRC) research using the fecal immunochemical test (FIT) has studied short-term screening results in predominantly urban areas. The purpose of this study was to evaluate the effectiveness of 2 outreach strategies embedded in a health literacy intervention on repeat CRC screening in rural community clinics. Methods A 2-arm randomized controlled trial was conducted in 4 rural clinics in Louisiana. During a regularly scheduled clinic visit, participants ages 50-75 received a FIT kit and brief educational intervention. Participants were randomized to receive an automated call or a personal call by a prevention counselor after 4 weeks and 8 weeks if FIT kits were not returned. In year 2, materials were mailed, and follow-up calls were conducted as in year 1. The primary outcome was repeat FIT-the return of the FIT kit in both years. Participants Of 568 eligible participants, 55% were female, 67% were African American, and 39% had low health literacy. Findings Repeat FIT rates were 36.5% for those receiving the automated call and 33.6% for those receiving a personal call (P = .30). No annual FITs were returned in 30% of participants, while only 1 FIT was returned by 35% of participants (31% only year 1 and 4% only year 2). Conclusion Sustaining CRC screening with FIT is challenging in rural clinics. A lower cost automated call was just as effective as the personal call in promoting repeat annual screening. However, more intensive strategies are needed to improve long-term FIT screening among rural participants.

Background Significant disparities exist in colorectal cancer (CRC) screening rates among those of low socioeconomic status, with fewer years of education, lacking health insurance, or living in rural areas. Methods A randomized controlled trial was conducted to compare the effectiveness of 2 follow-up approaches to a health literacy intervention to improve CRC screening: automated telephone call or personal call. Patients aged 50 to 75 years residing in 4 rural community clinics in Louisiana were given a structured interview that assessed demographic, health literacy and CRC screening barriers, knowledge, and attitudes. All were given health literacy-informed CRC education, a patient-friendly CRC screening pamphlet, simplified fecal immunochemical test (FIT) instructions, and a FIT kit, and a "teach-back" method was used to confirm understanding. Patients were randomized to 1 of 2 telephone follow-up arms. If they did not mail their FIT kit within 4 weeks, they received a reminder call and were called again at 8 weeks if the test still was not received. Results A total of 620 patients were enrolled. Approximately 55% were female, 66% were African American, and 40% had limited literacy. The overall FIT completion rate was 68%: 69.2% in the automated telephone call arm and 67% in the personal call arm. Greater than one-half of the patients (range, 58%-60%) returned the FIT kit without receiving a telephone call. There was no difference noted with regard to the effectiveness of the follow-up calls; each increased the return rate by 9%. Conclusions Providing FIT kits and literacy-appropriate education at regularly scheduled clinic visits with a follow-up telephone call when needed was found to increase CRC screening among low-income, rural patients. The lower cost automated call was just as effective as the personal call.

BACKGROUND As health systems shift toward value-based care, strategies to reduce readmissions and improve patient outcomes become increasingly important. Despite extensive research, the combinations of transitional care (TC) strategies associated with best patient-centered outcomes remain uncertain. METHODS Using an observational, prospective cohort study design, Project ACHIEVE sought to determine the association of different combinations of TC strategies with patient-reported and postdischarge health care utilization outcomes. Using purposive sampling, the research team recruited a diverse sample of short-term acute care and critical access hospitals in the United States (N = 42) and analyzed data on eligible Medicare beneficiaries (N = 7,939) discharged from their medical/surgical units. Using both hospital- and patient-reported TC strategy exposure data, the project compared patients "exposed" to each of five overlapping groups of TC strategies to their "control" counterparts. Primary outcomes included 30-day hospital readmissions, 7-day postdischarge emergency department (ED) visits and patient-reported physical and mental health, pain, and participation in daily activities. RESULTS Participants averaged 72.3 years old (standard deviation =10.1), 53.4% were female, and most were White (78.9%). Patients exposed to one TC group (Hospital-Based Trust, Plain Language, and Coordination) were less likely to have 30-day readmissions (risk ratio [RR], 0.72; 95% confidence interval [CI] = 0.57-0.92, p < 0.001) or 7-day ED visits (RR, 0.72; 95% CI, 0.55-0.93, p < 0.001) and more likely to report excellent physical and mental health, greater participation in daily activities, and less pain (RR ranged from 1.11 to 1.15, p < 0.01). CONCLUSION In concert with care coordination activities that bridge the transition from hospital to home, hospitals' clear communication and fostering of trust with patients were associated with better patient-reported outcomes and reduced health care utilization.

Background: Intensive lifestyle interventions (ILIs) are the first-line approach to effectively treat obesity and manage associated cardiometabolic risk factors. Because few people have access to ILIs in academic health centers, primary care must implement similar approaches for a meaningful effect on obesity and cardiometabolic disease prevalence. To date, however, effective lifestyle-based obesity treatment in primary care is limited. We examined the effectiveness of a pragmatic ILI for weight loss delivered in primary care among a racially diverse, low-income population with obesity for improving cardiometabolic risk factors over 24 months. Methods: The PROPEL trial (Promoting Successful Weight Loss in Primary Care in Louisiana) randomly allocated 18 clinics equally to usual care or an ILI and subsequently enrolled 803 (351 usual care, 452 ILI) adults (67% Black, 84% female) with obesity from participating clinics. The usual care group continued to receive their normal primary care. The ILI group received a 24-month high-intensity lifestyle-based obesity treatment program, embedded in the clinic setting and delivered by health coaches in weekly sessions initially and monthly sessions in months 7 through 24. Results: As recently demonstrated, participants receiving the PROPEL ILI lost significantly more weight over 24 months than those receiving usual care (mean difference, −4.51% [95% CI, −5.93 to −3.10]; P P P =0.76). Increases in high-density lipoprotein cholesterol were greater in the ILI than in the usual care group at both time points (mean difference at 24 months, 4.6 mg/dL [95% CI, 2.9–6.3]; P z score) decreased more in the ILI group than in the usual care group at both time points, with significant mean differences of the change of −0.31 (95% CI, −0.47 to −0.14; P P =0.01) at 24 months, respectively. Changes in total cholesterol, low-density lipoprotein cholesterol, triglycerides, and blood pressure did not differ significantly between groups at any time point. Conclusions: A pragmatic ILI consistent with national guidelines and delivered by trained health coaches in primary care produced clinically relevant improvements in cardiometabolic health in an underserved population over 24 months. Registration: URL: https://www.clinicaltrials.gov ; Unique identifier: NCT02561221.

Background The purpose of this study was to develop and administer surveys that assess patient and family caregiver experiences with care transitions and examine the psychometric properties of the surveys. The surveys were designed to ask about 1) the transitional care services that matter most to patients and their caregivers and 2) care outcomes, including the overall quality of transitional care they received, patient self-reported health, and caregiver effort/stress. Methods Survey items were developed based on a review of the literature, existing surveys, focus groups, site visits, stakeholder and expert input, and patient and caregiver cognitive interviews. We administered mail surveys with telephone follow up to patients recently discharged from 43 U.S. hospitals. Patients identified the caregivers who helped them during their hospital stay (Time 1 caregiver) and when they were home (Time 2 caregiver). Time 1 and Time 2 caregivers were surveyed by telephone only. The psychometric properties of the survey items and outcome composite measures were examined for each of the three surveys. Items that performed poorly across multiple analyses, including those with low variability and/or a high missing data, were dropped except when they were conceptually important. Results The analysis datasets included responses from 9282 patients, 1245 Time 1 caregivers and 1749 Time 2 caregivers. The construct validity of the three proposed outcome composite measures—Overall Quality of Transitional Care (patient and caregiver surveys), Patient Overall Health (patient survey) and Caregiver Effort/Stress (caregiver surveys) —was supported by acceptable exploratory factor analysis results and acceptable internal consistency reliability. Site-level reliability was acceptable for the two patient outcome composite measures, but was low for Caregiver Effort/Stress ( Conclusions Overall, the final patient and caregiver surveys are psychometrically sound and can be used by health systems, hospitals, and researchers to assess the quality of care transitions and related outcomes. Results from these surveys can be used to improve care transitions, focusing on what matters most to patients and their family caregivers.

Background: Low health literacy is common in general populations, but its prevalence in the inflammatory bowel disease (IBD) population is unclear. The objective of this study was to assess the prevalence of low health literacy in a diverse IBD population and to identify risk factors for low health literacy. Methods: Adult patients with IBD at a single institution from November 2017 to May 2018 were assessed for health literacy using the Newest Vital Sign (NVS). Demographic and socioeconomic data were also collected. Primary outcome was the prevalence of low health literacy. Secondary outcomes were length-of-stay (LOS) and 30-day readmissions after surgical encounters. Bivariate comparisons and multivariable regression were used for analyses. Results: Of 175 IBD patients, 59% were women, 23% were African Americans, 91% had Crohn disease, and mean age was 46 years (SD = 16.7). The overall prevalence of low health literacy was 24%. Compared to white IBD patients, African Americans had significantly higher prevalence of low health literacy (47.5% vs 17.0%, P < 0.05). On multivariable analysis, low health literacy was associated with older age and African American race (P < 0.05). Of 83 IBD patients undergoing abdominal surgery, mean postoperative LOS was 5.5 days and readmission rate was 28.9%. There was no significant difference between LOS and readmissions rates by health literacy levels. Conclusions: Low health literacy is present in IBD populations and more common among older African Americans. Opportunities exist for providing more health literacy-sensitive care in IBD to address disparities and to benefit those with low health literacy., Lay Summary Low health literacy exists in the inflammatory bowel disease (IBD) population. Older African Americans with IBD represent a subset at even higher risk for low health literacy. Opportunities exist for providing more health literacy-sensitive care in IBD to address disparities.

Introduction The purpose of this report is to describe barriers and solutions to the implementation and optimization of a pragmatic trial that tests an evidence-based, patient-centered, low literacy intervention promoting diabetes self-care in rural primary care clinics. Methods The two-arm pragmatic trial has been implemented in six rural family medicine clinics in Arkansas. It tests a self-management education and counseling intervention for patients with type 2 diabetes compared to enhanced usual care. Barriers and solutions were identified as issues arose and through interviews with clinic directors and clinic administrators and a focus group, interviews, and tracking reports with clinic health coaches who delivered the intervention. Results Barriers to optimizing enrollment, intervention delivery, and data collection were addressed through targeted education of and relationship building with leadership, changing enrollment oversight, and ongoing training of health coaches. Conclusions Successful implementation and optimization of this pragmatic clinical trial in rural primary care clinics was achieved through establishing common goals with clinic leadership, minimizing demands on clinic staff and administration, frequent contact and ongoing support of health coaches, and collaborative troubleshooting of issues with delivering the intervention.

Proper diabetes self-care requires patients to have considerable knowledge, a range of skills, and to sustain multiple health behaviors. Self-management interventions are needed that can be readily implemented and sustained in rural clinics with limited resources that disproportionately care for patients with limited literacy. Researchers on our team developed an evidence-based, patient-centered, low literacy intervention promoting diabetes self-care that includes: 1) the American College of Physicians (ACP) Diabetes Guide that uses plain language and descriptive photographs to teach core diabetes concepts and empower patients to initiate behavior change; 2) a brief counseling strategy to assist patients in developing short-term, explicit and attainable goals for behavior change ('action plans'); and 3) a training module for health coaches that prepares them to assume educator/counselor roles with the Diabetes Guide as a teaching tool. While the intervention has previously been field tested and found to significantly improve patient knowledge, self-efficacy, and engagement in related health behaviors, its optimal implementation is not known. This project took advantage of a unique opportunity to modify and disseminate the ACP health literacy intervention among patients with type 2 diabetes cared for at rural clinics in Arkansas that are Patient-Centered Medical Homes (PCMH). These practices all had health coaches that could be leveraged to provide chronic disease self-management mostly via phone, but also at the point-of-care. Hence we conducted a patient-randomized, pragmatic clinical trial in 6 rural PCMHs in Arkansas, targeting individuals with uncontrolled type 2 diabetes.

PURPOSE Despite concerted actions to streamline care transitions, the journey from hospital to home remains hazardous for patients and caregivers. Remarkably little is known about the patient and caregiver experience during care transitions, the services they need, or the outcomes they value. The aims of this study were to (1) describe patient and caregiver experiences during care transitions and (2) characterize patient and caregiver desired outcomes of care transitions and the health services associated with them. METHODS We interviewed 138 patients and 110 family caregivers recruited from 6 health networks across the United States. We conducted 34 homogenous focus groups (103 patients, 65 caregivers) and 80 key informant interviews (35 patients, 45 caregivers). Audio recordings were transcribed and analyzed using principles of grounded theory to identify themes and the relationship between them. RESULTS Patients and caregivers identified 3 desired outcomes of care transition services: (1) to feel cared for and cared about by medical providers, (2) to have unambiguous accountability from the health care system, and (3) to feel prepared and capable of implementing care plans. Five care transition services or provider behaviors were linked to achieving these outcomes: (1) using empathic language and gestures, (2) anticipating the patient’s needs to support self-care at home, (3) collaborative discharge planning, (4) providing actionable information, and (5) providing uninterrupted care with minimal handoffs. CONCLUSIONS Clear accountability, care continuity, and caring attitudes across the care continuum are important outcomes for patients and caregivers. When these outcomes are achieved, care is perceived as excellent and trustworthy. Otherwise, the care transition is experienced as transactional and unsafe, and leaves patients and caregivers feeling abandoned by the health care system.

Underserved and minority populations suffer from a disproportionately high prevalence of obesity and related comorbidities. Effective obesity treatment programs delivered in primary care that produce significant weight loss are currently lacking. The purpose of this trial is to test the effectiveness of a pragmatic, high intensity lifestyle-based obesity treatment program delivered within primary care among an underserved population. We hypothesize that, relative to patients who receive usual care, patients who receive a high-intensity, health literacy- and culturally-appropriate lifestyle intervention will have greater percent reductions in body weight over 24 months. Eighteen clinics (N = 803 patients) serving low income populations with a high proportion of African Americans in Louisiana were randomized to the intervention or usual car. Patients in the intervention participate in a high-intensity lifestyle program delivered by health coaches employed by an academic health center and embedded in the primary care clinics. The program consists of weekly (16 in-person/6 telephone) sessions in the first six months, followed by sessions held at least monthly for the remaining 18 months. Primary care practitioners in usual care receive information on weight management and the current Centers for Medicare and Medicaid Services reimbursement for obesity treatment. The primary outcome is percent weight loss at 24 months. Secondary outcomes include absolute 24-month changes in body weight, waist circumference, blood pressure, fasting glucose and lipids, health-related quality of life, and weight-related quality of life. The results will provide evidence on the effectiveness of implementing high-intensity lifestyle and obesity counseling in primary care settings among underserved populations. Trial Registration: ClinicalTrials.gov Identifier NCT02561221

The purpose of this pilot study was to assess Chronic Myeloid Leukemia (CML) patients’ adherence to, beliefs about, and barriers to oral anticancer agents (OAC) using brief self-report measures in community-based cancer clinics. Patients completed a structured interview including a health literacy assessment, a Brief Medication Questionnaire, two single-item self-report adherence questions, and the Medications Adherence Reasons Scale. Of the 86 participants, 88.4% were white, 55.8% male, mean age, 58.7 years, and 22.1% had limited health literacy. Nonadherence (missing at least one dose in the last week) was reported by 18.6% of participants and associated (p &lt, 0.003) with less-than-excellent perceived ability to take CML medications (16.3%). Black participants reported more difficulty taking CML medications than white participants (28.6% vs. 8.3%, p = 0.053). Among all participants, 43.0% reported their CML medicine was ineffective and 24.4% that taking CML pills was somewhat to very hard. The most common reasons for missing a dose were simply missed it (24.4%) and side effects (18.6%). Most patients perceived their ability to take CML medication was good to excellent, yet nearly one in five reported missing at least one dose in the last week. Brief, no-cost self-report assessments to screen CML patients’ OAC adherence, barriers, and beliefs could facilitate counseling in busy community cancer clinics.

Clinical health outcomes and health disparities can be improved through interprofessional collaborations among multidisciplinary clinicians, health care services researchers, and patients. Bridging gaps between community clinics and urban academic centers allows added valuable perspectives that can lead to improved care and extend clinical research. Nurse practitioners (NPs) who serve as primary care providers in many rural community clinics can facilitate access to clinical trials for patients who are rarely included in health care services research as well as coordinate interprofessional research team collaboration. A NP working in a rural clinic can assist academic-based research teams in designing feasible strategies to address disparities and improve health care of underserved populations. The purpose of this article was to provide an example of a rural provider/urban academic research team collaborating to conduct a health literacy-directed randomized controlled trial to improve colorectal cancer screening in isolated rural community clinics.

This study investigated associations between cardiovascular health (CVH), adiposity, and food insecurity by race, sex, and health literacy in a sample of 800 underserved patients with obesity (body mass index [BMI] &ge, 30 kg/m2). CVH was assessed using American Heart Association Life&rsquo, s Simple 7 (LS7) and adiposity was estimated using BMI and waist circumference (WC). Mixed models including interaction terms between food insecurity and sex, race, and health literacy were analyzed for LS7, BMI, and WC. Stratified models were analyzed as indicated by significant interactions. Mean BMI and WC were 37.3 kg/m2 (4.6 SD) and 113.5 cm (12.4 SD), respectively. Among patients, 31% were food insecure and 31% had low health literacy. There were significant positive associations between food insecurity and BMI (p = 0.03) and WC (p = 0.03) in the overall sample. In sex-stratified models, women who were food insecure had higher BMI (p = 0.02) and WC (p = 0.007) than their food secure counterparts. Further, food insecure patients with better health literacy had greater BMI (p = 0.004) and WC (p = 0.007) than their food secure counterparts. Results suggest that adiposity is a greater burden in food insecure patients, which may be an important consideration for obesity treatment in underserved populations.

OBJECTIVES: Investigate differences in the associations between adiposity, cardiovascular health (CVH), and food insecurity by key social determinants (sex, race, and health literacy) in a sample of underserved patients. METHODS: The sample included 800 patients (21–74 years old; 67% African American; 84% female) with obesity (body mass index [BMI] ≥ 30). Adiposity was assessed using BMI and waist circumference (WC). CVH was assessed using the American Heart Association Life's Simple 7. Food insecurity was determined by the 6-Item Food Security Survey. Health literacy was measured using the REALM-SF. Mixed models with interaction terms between food insecurity and sex, race, and health literacy were analyzed for BMI, WC, and CVH. Stratified models were then analyzed as indicated by significant interaction terms. RESULTS: Mean BMI, WC, and CVH were 37.3 kg/m(2) (±4.6), 113.5 cm (±12.4), 6.7 (±1.9), respectively. Thirty-one % of patients were food insecure and 31% had low health literacy. Significant food insecurity by sex interactions were seen for adiposity. Sex-stratified models showed women who were food insecure had greater BMI (38.2 vs. 37.2 kg/m(2); P = 0.02) and WC (114.0 vs 111.2 cm; P = 0.007) than food secure counterparts, but associations were not significant in men. Significant food insecurity by health literacy interactions were also seen for adiposity. Health literacy-stratified models showed food insecure participants with better health literacy had greater BMI (39.1 vs. 37.7 kg/m(2); P = 0.004) and WC (121.7 vs. 118.2 cm; P = 0.007) than food secure counterparts, but associations were not significant in those with low health literacy. No significant interactions were observed for race. CONCLUSIONS: Significant differences in adiposity were seen in food insecure vs. food secure women, as well as in food insecure vs. food secure patients with better health literacy. These data suggest that adiposity is a greater burden in food insecure patients and may pose challenges for obesity treatment in underserved populations. FUNDING SOURCES: This research was supported by the PCORI (#OB-1402–10,977), the NIGMS of the NIH that funds the Louisiana Clinical and Translational Science Center (1 U54 GM104940), and NORC Center Grant “Nutrition and Metabolic Health Through the Lifespan” sponsored by NIDDK (#P30DK072476).

Disparities exist in enrollment in clinical trials and biorepositories among adults with low socioeconomic status, racial and ethnic minority groups and individuals who live in rural areas. Diverse participation is necessary to identify the most effective treatments in different groups. The purpose of this study was to use qualitative methods to identify factors that may affect the likelihood that members of underrepresented groups choose to participate in clinical trials and/or biobanking. We conducted 14 focus groups and seven telephone interviews in urban and rural areas of Louisiana to: (1) identify barriers and facilitators to participation; and (2) elicit input in crafting clear, culturally appropriate language and recruitment strategies. Of 103 participants, 25 were safety-net healthcare providers, 18 were primary care or oncology clinic patients, and 60 were members of social and faith-based groups. Patients and community participants were English-speaking, 79% were African American, 81% were female and 24% lived in rural areas. Barriers to participation identified were lack of knowledge about clinical trials and biobanks; limited specific information and access to participation, trust and privacy concerns about clinical trials and biobanking Facilitators included: altruism, high interest in medical research particularly studies that might benefit them or their families; plain language, culturally appropriate information; convenient access to studies; and input of a trusted provider. In addition, all primary care providers were interested in having clinical trial options available for their patients but did not have time to search for available trials. Results of this study can inform the development of education materials and strategies to increase participation of underrepresented groups in clinical trial and biobanking.

BACKGROUND: Patient misunderstanding of prescription drug label instructions is a common cause of unintentional misuse of medication and adverse health outcomes. Those with limited literacy and English proficiency are at greater risk. OBJECTIVE: To test the effectiveness of a patient-centered drug label strategy, including a Universal Medication Schedule (UMS), to improve proper regimen use and adherence compared to a current standard. DESIGN: Two-arm, multi-site patient-randomized pragmatic trial. PARTICIPANTS: English- and Spanish-speaking patients from eight community health centers in northern Virginia who received prescriptions from a central-fill pharmacy and who were 1) ≥30 years of age, 2) diagnosed with type 2 diabetes and/or hypertension, and 3) taking ≥2 oral medications. INTERVENTION: A patient-centered label (PCL) strategy that incorporated evidence-based practices for format and content, including prioritized information, larger font size, and increased white space. Most notably, instructions were conveyed with the UMS, which uses standard intervals for expressing when to take medicine (morning, noon, evening, bedtime). MAIN MEASURES: Demonstrated proper use of a multi-drug regimen; medication adherence measured by self-report and pill count at 3 and 9 months. KEY RESULTS: A total of 845 patients participated in the study (85.6 % cooperation rate). Patients receiving the PCL demonstrated slightly better proper use of their drug regimens at first exposure (76.9 % vs. 70.1 %, p = 0.06) and at 9 months (85.9 % vs. 77.4 %, p = 0.03). The effect of the PCL was significant for English-speaking patients (OR 2.21, 95 % CI 1.13-4.31) but not for Spanish speakers (OR 1.19, 95 % CI 0.63-2.24). Overall, the intervention did not improve medication adherence. However, significant benefits from the PCL were found among patients with limited literacy (OR 5.08, 95 % CI 1.15-22.37) and for those with medications to be taken ≥2 times a day (OR 2.77, 95 % CI 1.17-6.53). CONCLUSIONS: A simple modification to pharmacy-generated labeling, with minimal investment required, can offer modest improvements to regimen use and adherence, mostly among patients with limited literacy and more complex regimens. Trial Registration (ClinicalTrials.gov): NCT00973180, NCT01200849.

Objectives Our objective was to determine the effectiveness of 3 approaches to encourage completion of fecal occult blood testing (FOBT) in the third year of the intervention. Methods Between 2008 and 2011, a quasi-experimental intervention was conducted in 8 predominantly rural Federally Qualified Health Centers. Clinics were randomly assigned to enhanced care (screening recommendation and FOBT kit mailed annually), education (patients additionally received a health literacy appropriate pamphlet and simplified FOBT instructions), or nurse support (same as education but with nurse follow-up). Participants included 206 patients with negative FOBTs in years 1 and 2; ages 50-85, 80% female, 70% African American, and 52% had limited health literacy. The main outcome measure was completion of a third annual FOBT. Results Third-year FOBT rates were 48% overall, 34.2% enhanced care, 59.6% education, and 47.4% nurse support (p = .21), even after adjustment for sex, marital status, and health literacy. Conclusion All mailed interventions were similarly effective in sustaining rates of FOBT screening. Post hoc analyses of the results analyzed by health literacy skills found that patients with both limited and adequate health literacy skills were more likely to complete FOBTs when mailed simplified instructions.

This three arm study was designed to make CRC screening with FOBTs more accessible, understandable and actionable for patients cared for in predominantly rural Federally Qualified Health Centers. Patients in an enhanced version of usual care received an annual CRC recommendation and FOBT kit; those in the education arm additionally received brief literacy and culturally appropriate education and those in the nurse arm received the education by a nurse manager who followed up by telephone. Baseline FOBT rates in this population were 3 %. We evaluated if FOBT rates could be sustained over 3 years. A three-arm, quasi-experimental evaluation was conducted among eight clinics in Louisiana. Screening efforts included: (1) enhanced usual care, (2) literacy-informed education of patients, and (3) education plus nurse support. Overall, 961 average-risk patients, ages 50-85, eligible for routine CRC screenings were recruited. The primary outcome was completing three annual FOBT tests. Of 961 patients enrolled, 381 (39.6 %) participants did not complete a single FOBT, 60.4 % completed at least one FOBT of which 318 (33.1 %) completed only one, 162 (16.9 %) completed two and 100 (10.4 %) completed three FOBTs over the 3-year period (the primary study outcome). The primary outcome, return of three FOBT kits over the 3-year period, was achieved by 4.7 % in enhanced care, 11.4 % in education and 13.6 % in the nurse arm (p = 0.005). Overall 3-year FOBT screening rates were not sustained with any of the three interventions, despite reports of promising interim results at years 1 and 2. New strategies for sustaining FOBT screening over several years must be developed.

Introduction: Colorectal cancer (CRC), the second leading cause of cancer death in the United States, can be significantly reduced if it is detected early. Although overall CRC screening rates have increased significantly, disparities persist among low-income individuals, adults with low literacy and those living in rural areas. These groups all have screening completion rates below 50%. Objectives: To assess patient knowledge, beliefs, and self-efficacy about CRC screening and compare the effectiveness of two health literacy informed telephone follow-up strategies to improve annual screening over a three-year period with fecal immunochemical test (FIT) in rural community clinics. Methods: A two-arm, randomized controlled trial is being implemented in four community clinics. Clinics reported CRC baseline screening rates of 3% to 5%. Eligible patients, age 50-75, were recruited at the clinic prior to a scheduled appointment. A research assistant (RA) conducted a baseline structured interview measuring CRC screening knowledge, beliefs, and self-efficacy. The RA then recommended screening and gave brief literacy and culturally appropriate education using a pamphlet (4th-grade level), the FIT kit with preaddressed envelope, simplified instructions (3rd-grade level) and a demonstration of how to use it. At four weeks patients who had not returned their kit received either 1) a personal follow-up call (PC) from a central prevention coordinator using motivational interviewing skills and reminding them to complete and mail FIT kits, or 2) an automated follow-up call (AC) using plain language and motivational messages encouraging patients to complete and mail the FIT. Outcomes include FIT completion after intervention, and again at 12 and 24 months. Results: 620 patients not up-to-date were enrolled: 308/AC and 306/PC; 66% were African American, 55% women; 40% had limited literacy. During Year 1, 69% completed screening in AC arm versus 67% in PC arm. During Year 2, percentage screened decreased: 40% screened in AC arm and 37% in PC arm. Number of patients who needed at least one follow-up call increased: 74% in both arms needed at least 1 reminder call. Among those called, 19% in the AC arm completed their kit versus 15% in the PC arm. To date in Year 3, 32% screened in AC and 34% in PC. Conclusions: Simplified instructions accompanied by a face-to-face demonstration of FIT, and use of “teach back” to confirm understanding with a follow-up call if needed, facilitated completion rates of all patients, particularly those with limited literacy. Providing FIT + literacy appropriate education at regularly scheduled clinic visit with follow-up call (if needed) increased CRC screening rates of low-income, rural patients. Sustaining annual screening with FIT is challenging. In year 2 < 40% completed FIT. Follow-up calls were essential. Only 1/4 completed FIT without phone prompt. Lower-cost automated call has proven to be just as effective as personal call in both years 1 and 2. FIT is only effective if completed annually. This abstract is also being presented as Poster B099. Citation Format: Connie L. Arnold, Terry C. Davis, James Morris, Peggy Murphy, Glenn Mills. CRC screening in rural community clinics using the fecal immunochemical test (FIT): Issues with repeat screening [abstract]. In: Proceedings of the Eleventh AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2018 Nov 2-5; New Orleans, LA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2020;29(6 Suppl):Abstract nr PR12.

69 Background: The Healthy People 2020 initiative aims to increase colorectal cancer (CRC) screening. The common CRC screening options are FIT, FOBT, sigmoidoscopy, and colonoscopy. Colonoscopy allows visualization of the entire colon and offers therapeutic benefit whereas stool tests are less invasive, cost-effective and are easily available. Inequities exist in CRC screening among rural residents which may be contributed to a lower level of education, income, health insurance and access to health care. The purpose of the study is to identify the impact of geographic region on the preference of CRC screening modality among Louisiana adults. Methods: We performed a retrospective cohort study among age-eligible Louisiana adults who had CRC screening either with colonoscopy or stool-based tests using the 2016 Behavioral Risk Factor Surveillance System database (n = 1372). We examined demographic characteristics among participants who had CRC screening with colonoscopy versus who had a stool-based test. Multivariable logistic regression analysis evaluated the association of geographic region and the preference of CRC screening. Results: Participants age 65-75 years old were 36% less likely to have a colonoscopy as compared to age 50-64 years (p = 0.0008). African Americans and Hispanic Americans were 34% (p < 0.006) and 55% (p = 0.057) less likely to have a colonoscopy as compared to Caucasian Americans, respectively. Medicaid and Medicare participants were 82% (p < 0.0001) and 52% (p < 0.0001) less likely to have a colonoscopy compared to participants with private insurance, respectively. After adjusting for age, race/ethnicity, education, income, and insurance the odds of screening colonoscopy was 29% lower for rural residents compared to urban residents of Louisiana (OR 0.71 95% CI 0.53 - 0.94). Conclusions: Individuals residing in rural parishes of Louisiana were more likely to have a stool-based test for CRC screening. Health care providers while considering the reliability and feasibility of CRC screening modality should also incorporate patient’s preferences while offering the screening tests to increase the rate of CRC screening.

To gain a better understanding of the patient and caregiver experience during care transitions and to describe the desired outcomes of transitions in care, 138 patients and 110 family caregivers participated in focus groups or interviews at six health networks across the U.S. Principles of grounded theory were used to analyze transcripts. Overall, patients and caregivers preferences were to: (1) feel prepared and capable of implementing the care plan, (2) know who was accountable for their care, and (3) feel cared for/about by medical providers. Five care transitional care elements were linked to achieving the preferred outcomes: a) providing actionable information; b) collaborative discharge planning; c) using empathic language and gestures; d) anticipating the patient’s needs to support self-care at home, and e) providing uninterrupted care with minimal handoffs. Clear accountability, care continuity and caring attitudes across the care continuum are important outcomes for patients and caregivers.

Today, when consumers receive prescription drug pharmacy leaflets (also known as ‘consumer medication information’ or CMI), they often appear in small font size, with cluttered layouts, and distracting information. This problem has attracted the attention of the U.S. Food and Drug Administration in advocating for more comprehendible, accurate, and easy-to-access CMI formats. Our study of four different CMI prototypes shows that an expanded Over-the-Counter (OTC) Drug Facts prototype is the best for improving comprehension accuracy, and is especially effective for those with lower health literacy and health motivation. A simpler OTC prototype did not aid accuracy scores due in part to its lack of complexity; whereas the most complex prototype (the revised medication guide – similar to most CMI today) reduced leaflet likability and usage intentions. Finally, continued leaflet availability improved accuracy scores for lower health literacy and health motivation respondents. Implications for marketing and pub...

Our previous three-arm comparative effectiveness intervention in community clinic patients who were not up-to-date with screening resulted in mammography rates over 50% in all arms.Our aim was to evaluate the effectiveness and cost-effectiveness of the three interventions on improving biennial screening rates among eligible patients.A three-arm quasi-experimental evaluation was conducted in eight community clinics from 2008 to 2011. Screening efforts included (1) enhanced care: Participants received an in-person recommendation from a research assistant (RA) in year 1, and clinics followed usual clinic protocol for scheduling screening mammograms; (2) education intervention: Participants received education and in-person recommendation from an RA in year 1, and clinics followed usual clinic protocol for scheduling mammograms; or (3) nurse support: A nurse manager provided in-person education and recommendation, scheduled mammograms, and followed up with phone support. In all arms, mammography was offered at no cost to uninsured patients.Of 624 eligible women, biennial mammography within 24-30 months of their previous test was performed for 11.0% of women in the enhanced-care arm, 7.1% in the education- intervention arm, and 48.0% in the nurse-support arm (p0.0001). The incremental cost was $1,232 per additional woman undergoing screening with nurse support vs. enhanced care and $1,092 with nurse support vs. education.Biennial mammography screening rates were improved by providing nurse support but not with enhanced care or education. However, this approach was not cost-effective.

Breast and colorectal cancer (CRC) screening in safety-net settings is underused.1-3 Screening rates for these cancers remain persistently lower among disadvantaged populations including low-income women, those with no health insurance, those with lower health literacy and fewer years of education, racial and ethnic minorities, and those who live in rural areas.4-14 The reduction of these screening disparities is a national public health priority.15 The Community Preventive Service Task Force's systematic review on the effectiveness of joint interventions to increase the rates of breast, cervical, and CRC screening found that one-on-one education, patient reminders, and enhancing access to screening services were effective.16 Another systematic review looking at multiple cancer screening also found that provider audits and culturally appropriate mail and telephone outreach improved breast and CRC screening rates.17 Few initiatives have been specifically developed to improve multiple-cancer screening rates in safety-net primary care clinics. In community clinics that participate in a county-funded health plan in Florida, a cancer screening office reminder system using chart stickers was effective in increasing joint rates of mammograms and fecal occult blood tests (FOBTs).18 Mammogram and FOBT screening rates among inner-city patients in Rochester, New York, increased with the use of a multimodal intervention of repeated letters and automated phone calls and a mailed FOBT kit with a point-of-care prompt if the patient had an appointment.19 An expansion of that study found that personal patient reminder calls and provider and patient prompts delivered at a patient-initiated visit were more effective in improving screening rates among poor and minority inner-city patients than were reminder letters alone or letters with automated calls.20 Although all of those interventions targeted 2 or more cancers, none targeted rural areas. Our team developed and evaluated a health literacy-informed intervention designed to promote mammogram and FOBT screening in rural and inner-city populations that were at higher risk for not undergoing cancer screening: low-income and uninsured women who were cared for in Federally Qualifed Health Centers (FQHCs) in Louisiana that were not participating in state or national screening programs. FQHCs are located in areas designated as medically underserved and provide care nationally to 20 million individuals regardless of their insurance status.21 The objective of this study was to test 3 strategies to promote joint breast and CRC screening: enhanced care, which ensured that women received screening recommendations and access to both tests; health literacy-informed educational materials with accompanying “teach back” to confirm comprehension; 22, 23 or use of the health literacy-informed education strategy with telephone follow-up by a nurse. All of the strategies promoted use of mammography at a rural community hospital or the nearest public hospital and of the FOBT, the most feasible, cost-effective screening option for CRC in low-income and uninsured patients.24-25 This report looks at whether women completed both tests. Given the resource-constrained FQHCs environment, we also evaluated the cost effectiveness of the interventions targeting breast and CRC. Cancer screening interventions are a priority in Louisiana because the state has high rates of cancer mortality, ranking third among states in breast cancer deaths and fourth in colon cancer deaths.26

BACKGROUND: This study was designed to develop and validate a brief adolescent health literacy assessment tool (Rapid Estimate of Adolescent Literacy in Medicine Short Form [REALM-TeenS]). METHODS: We combined datasets from 2 existing research studies that used the REALM-Teen (n = 665) and conducted an item response theory analysis. The correlation between scores on the original 66-item REALM-Teen and the proposed REALM-TeenS was calculated, along with the decision consistency across forms with respect to grade level assignment of each adolescent and coefficient α. The proposed REALM-TeenS was validated with original REALM-Teen data from a third independent study (n = 174). RESULTS: Items with the largest discriminations across the scale, from low to high health literacy, were selected for inclusion in REALM-TeenS. From those, a set of 10 items was selected that maintained a reasonable level of SE across ability estimates and correlated highly (r = 0.92) with the original REALM-Teen scores. The coefficient α for the 10-item REALM-TeenS was .82. There was no evidence of model misfit (root mean square error of approximation < 0.001). In the validation sample, REALM-TeenS scores correlated highly with scores on the original REALM-Teen (r = 0.92), and the decision consistency across both forms was 80%. In pilot testing, administration took ∼20 seconds. CONCLUSIONS: The REALM-TeenS offers researchers and clinicians a brief validated screening tool that can be used to assess adolescent health literacy in a variety of settings. Scoring guidelines ensure that reading level assessment is appropriate by age and grade.

Objectives To improve patient colonoscopy bowel preparation with a newly developed simplified instruction sheet in a safety-net hospital system. Methods Bowel preparation quality was compared in a retrospective chart review of 543 patients, 287 of whom received standard instructions (9th grade reading level) between November 2015 and February 2016, and 256 of whom received simplified instructions (6th grade level) between March and May 2016. Instructions were mailed to all patients. The primary outcome was bowel preparation quality recorded by the endoscopist as optimal or suboptimal preparation. Results 543 medical records were reviewed and results indicated a significant association between the instructions used and preparation quality with patients receiving simplified instructions being significantly more prepared (69.1% vs 65.5%) and having a lower cancellation rate (4.7% vs 10.5%), p = .042. Conclusions A no-cost simplified colonoscopy instruction sheet improved bowel preparation among patients in an academic safety-net health system.

Background: Rural women lag rural men and urban women in colon cancer (CRC) screening completion. Objective: To identify rural female patients’ knowledge, beliefs, barriers, self-efficacy, prior recommendation and completion of CRC screening using an FOBT and to compare these factors by health literacy (HL) level. Methods: This descriptive study was conducted between 2015 and 2016 in 4 rural community clinics in South Lousiana. Patients overdue for screening were given a structured interview by a research assistant. Results: 339 women were enrolled, mean age 58.5, 32% had limited HL, 66% were African American. Most (91.7%) had heard of CRC, yet only 71% knew of any CRC screening tests. Women with adequate HL had greater knowledge of specific tests than those with limited HL (78.4% vs 56.6%, p