Class of 2011 Abstract / OBJECTIVES: To compare pharmacists’ perceptions of patients’ health literacy levels to their measured health literacy levels. METHODS: This was descriptive study that included thirty patients from two independent pharmacies where they were administered a health literacy survey at random during their routine visit to the pharmacy. Each participant’s health literacy assessment was scored and assigned to a corresponding literacy level. Pharmacists from each store were then surveyed as to what they perceived each patient’s health literacy level to be. RESULTS: Twenty-eight of the thirty participants (93%) obtained the highest literacy score possible in the assessment. Two participants scored lower literacy levels and were both non-whites who were currently taking six or more medications and over the age of 50. No significant differences with respect to age, gender, education level, number of previous conversations with the pharmacist, or number of current medications were found as compared to measured literacy level. Actual literacy scores as well as perceived literacy levels between sites were also found to be insignificant (p=0.17 and p=0.58 respectively). With respect to race, there was a significant difference between whites vs. non-whites relative to REALM scores (p<0.001). Analysis of the difference between actual literacy scores and perceived scores were unable to be determined.       CONCLUSION: Based on the two participants who had lower literacy levels, this may suggest a disparity in health literacy with respect to race, age, and number of concurrent medications. However, due to lack of study variability, the significance of the difference was unable to be determined and conducting a larger study with more diverse settings, demographics, and larger sample size is suggested.

Cardiovascular diseases are major causes of mortality and hospitalization for adult Indigenous peoples. Historical, socio-economic, environmental and cultural risk factors have been identified in the literature and new evidence is emerging regarding culturally relevant health promotion approaches for Indigenous peoples at risk of developing or currently experiencing cardiovascular disease. Self-management of care is considered a central component to effective cardiovascular disease management. This approach requires a working knowledge and understanding of cardiovascular disease medications, and an ability to effectively communicate with healthcare practitioners. Another important associated risk factor for Indigenous peoples with heart disease, is the gap between patient - practitioner understanding of heart disease. The biomedical perspective supported by Western scientific evidence, makes little room for Indigenous knowledge. Indigenous peoples may wish to include Indigenous knowledge and/or Traditional Medicine in their self-care approach. The findings of this research demonstrates that Indigenous peoples primarily have a biomedical understanding of their heart disease and most are unaware of how various socio-historical and socio-cultural factors such as the negative inter-generational impact of residential school and contemporary experiences of oppression and discrimination are linked to their heart disease. This situation can be attributed to an Indigenous knowledge diaspora experience that includes the severance of access to Indigenous knowledge and Indigenous languages during the residential school period and the dominance of biomedicine in health care delivery. The concept of ‘diaspora health literacy’ is critically discussed as a potential tool to address the Indigenous knowledge diaspora barrier. It is proposed that Indigenous peoples with heart disease can enhance their self-care when culturally relevant health literacy approaches are available to them. In turn, healthcare practitioners can broker an ‘Indigenous therapeutic relational space’ with their Indigenous patients by initiating a culturally relevant health literacy assessment and a harmonized implementation model. / Dissertation / Doctor of Philosophy (PhD)

MASTER OF SCIENCE (2017), McMaster University, Hamilton ON (Department of Global Health) TITLE: A comprehensive approach to health literacy: validating the all aspects of health literacy scale (AAHLS) in a representative sample of Arabic-speaking adult Syrian refugees AUTHOR: Raafia Siddiqui, BSc Hons. (York University, 2014) SUPERVISOR: Dr. K. Bruce Newbold NUMBER OF PAGES: vii, 92 / The purpose of this study is to quantify current health literacy levels amongst a segment of the Syrian refugee population in Canada by translating and validating an existing comprehensive health literacy assessment tool, the All Aspects of Health Literacy Scale (AAHLS) into Arabic. This study (1) determined functional, communicative and critical health literacy levels amongst Syrian refugees. Functional and critical health literacy was comparatively low but respondents seemed able to effectively communicate with their providers and access supports to read and fill in health documents. Significant correlates of low health literacy were presence of long-term health conditions and place of origin (country versus refugee camp). This study also validated the AAHLS in Arabic-speaking Syrian refugees, with a Cronbach’s alpha of 0.67 for the overall scale and 0.63 for health literacy items. The overall scale had high content validity. The feasibility of this instrument as a self-administered screening tool in clinical or community settings was demonstrated with a high response rate of 0.86. / Thesis / Master of Science (MSc) / Health literacy looks at an individual's ability to read, understand and interpret health information and ultimately use it to exert greater control over their health. The purpose of this study is to understand the factors that influence health literacy levels amongst a segment of the Syrian refugee population in Canada by translating and validating an existing comprehensive health literacy assessment tool, the All Aspects of Health Literacy Scale (AAHLS) into Arabic. This study (1) determined functional (reading and filling in health documents), communicative (speaking to health providers) and critical health (assessing the relevance and appropriateness of health information) literacy levels amongst Syrian refugees. Functional and critical health literacy was comparatively low but respondents seemed able to effectively communicate with their providers and access supports to read and fill in health documents. Low health literacy was associated with having a long-term health conditions and staying in a refugee camp. This study found the translated AAHLS to be reliable, with a Cronbach’s alpha of 0.67 for the overall scale and 0.63 for health literacy items. The overall scale had high content validity. The feasibility of this instrument as a self-administered screening tool in clinical or community settings was demonstrated with a high response rate of 0.86.

BACKGROUND:Health literacy (HL) is an important public health issue. Current measures have drawbacks in length and/or acceptability. The US-developed Newest Vital Sign (NVS) health literacy instrument measures both reading comprehension and numeracy skills using a nutrition label, takes 3 minutes to administer, and has proven to be acceptable to research subjects. This study aimed to amend and validate it for the UK population.METHODS:We used a three-stage process / (1) a Delphi study with academic and clinical experts to amend the NVS label to reflect UK nutrition labeling (2) community-based cognitive testing to assess and improve ease of understanding and acceptability of the test (3) validation of the NVS-UK against an accepted standard test of health literacy, the Test of Functional Health Literacy in Adults (TOFHLA) (Pearson's r and the area under the Receiver Operating Characteristic (ROC) curve) and participant educational level. A sample size calculation indicated that 250 participants would be required. Inclusion criteria were age 18-75 years and ability to converse in English. We excluded people working in the health field and those with impaired vision or inability to undertake the interview due to cognitive impairment or inability to converse in English.RESULTS:In the Delphi study, 28 experts reached consensus (3 cycles). Cognitive testing (80 participants) yielded an instrument that needed no further refinement. Validation testing (337 participants) showed high internal consistency (Cronbach's Alpha = 0.74). Validation against the TOFHLA demonstrated a Pearson's r of 0.49 and an area under the ROC curve of 0.81.CONCLUSIONS:The NVS-UK is a valid measure of HL. Its acceptability and ease of application makes it an ideal tool for use in the UK. It has potential uses in public health research including epidemiological surveys and randomized controlled trials, and in enabling practitioners to tailor care to patient need.

Older adults constitute a growing population in the United States. A disproportionate percentage of this population experience chronic illnesses and need to recall information important to prevent complications of illness and to self-manage their condition. One example of the need to retain information is to recall the risk factors for ischemic stroke to prevent the damaging effects of stroke.Factors that could influence the recall of health information include age-related changes in cognition, specifically working memory capacity. Research supports that older adults have working memory capacity limitations. Older adults may also experience low health literacy that in combination with declines in working memory could further influence recall of health information.The purpose of this study was to describe the predictive relationships of working memory capacity and health literacy on the recall of the warning signs of stroke in a sample of older community dwelling elders.Fifty-six participants, ranging in age from 68-99 years of age (M= 80 years of age) were recruited from two sites, a Senior Center and Retirement Residence. A brochure published by the American Heart and Stroke Association, "Let's Talk About Stroke" was the tool used to deliver the health information regarding the five warning signs of stroke. Personal factors including demographic and medical variables were collected in this study. Working Memory was assessed using the Wechsler Adult Intelligence Scale III, Working Memory Index (WMI). Health literacy was determined using the Short Test of Functional Health Literacy in Adults (STOFHLA). Participants were asked to recall the health information they were asked to read regarding the five warning signs of stroke at the conclusion of the study visit.Findings indicated that the key variables working memory and health literacy were independently and positively correlated to recall (p < .01); however, regression analysis did not demonstrate an interaction between the two key variables and recall.The findings from this study explore the associations between working memory, health literacy and personal factors and support that these key predictors may be related to the older adults ability to successfully recall health information.

Class of 2012 Abstract / Specific Aims: The objective of this study is to first assess whether student pharmacist interns feel they can gauge patient health literacy levels with confidence, second to assess which methods are used most commonly in practice by student pharmacists to assess patient health literacy, and third to determine what techniques student pharmacist interns most often employ to communicate more effectively to patients with low health literacy. Methods: The questionnaire consisted of questions about demographics, and knowledge/experiential based questions. Key questions were: How well do you feel you are able to assess patient health literacy? How often do you use the following techniques to assess patient health literacy? (Observe contextual clues, Observe patient word pronunciation, Observe patient willingness to talk, Assess by demographics) When counseling low health literacy patients, how often do you use the following communication techniques? (Speak slowly, Give extra written material, Repeat information, Ask patient to repeat information, Ask if patient understands English, Avoid complicated medical terms). The answers to these questions are measured on a likert scale. Data from the questionnaire was analyzed using one sample t tests and paired t tests. Main Results: Regarding the first primary objective, on a scale of 1 to 5, with confidence measured 3 or greater and no confidence measured 2 or less, student intern pharmacists are statistically significantly confident in their ability to gauge patient health literacy (p< 0.001). There is no statistically significant difference in confidence in ability to gauge patient health literacy between males and females. The method student pharmacist interns used for assessing patient health literacy with the highest average use was observing patient willingness to talk (3.65 +/- 1.01) followed by observing patient word pronunciation (3.57 +/- 0.97), assessing patient demographics (race, age, ability to pay, culture, gender) (3.23 +/- 1.16) and observing contextual clues (patients identify pills by color, asks to be read to, etc) (3.04 +/- 1.04). There was no statistically significant difference between observing patient willingness to talk versus observing patient word pronunciation (p=0.55). There is a statistically significant difference between observing patient willingness to talk versus assessing patient demographics (p=0.011). The technique for improving communication with patients with low health literacy with the highest average use was avoiding complicated medical terms (3.97 +/- 0.95) followed by speaking slowly (3.91 +/- 0.89), repeating information (3.85 +/- 0.73), giving extra written material (3.02 +/- 1.36), asking patients if they understand English (2.85 +/- 1.21) and asking patients to repeat information. (2.39 +/- 1.02). There is a statistically significant difference between avoiding complicated medical terms and giving out extra written material (p<0.001) and speaking slowly and giving out extra written material (p<0.001). Conclusions: We conclude that students pharmacists working as interns are quite confident in their ability to assess patient health literacy, that observing patient willingness to talk is be the most commonly used method to assess patient health literacy, and that avoiding complicated medical terms is be the most commonly used technique student pharmacist interns use to communicate more effectively with patients who have low health literacy.

Low literacy remains a problem across the developed world. Health literacy has emerged as a specialist literacy, although its conceptualisation and measurement overlap with those of functional literacy. The social practice view, which conceptualises literacy as an activity rather than a skill, is useful in examining literacy-related practices and demands in healthcare contexts. Associations between low functional or health literacy and poorer health outcomes have been established in the research literature but studies have included participants whose low literacy may be obvious to healthcare providers and others. This thesis presents first a systematic review that focuses on literacy and health outcomes in the ‘hidden population’ with low literacy, defined as those of working age whose first language is that of their resident country but who score low on literacy measures. The review concludes that there is a link between low literacy and poorer health in this ‘hidden population’ but that potential pathways have not been explored to any extent. The thesis then presents a primary research study which sought to explore links between low literacy and poor health from the perspectives of people with low literacy; and how the health service might respond to address the issues raised. The findings from 25 in-depth interviews and 2 focus groups with adult learners highlighted the various ways that people with low literacy struggle with written and spoken communication in clinical encounters and in self-care activities. They further revealed that stigma frequently plays a central role in the social practices of those with low literacy, affecting their mental wellbeing and social relationships, including those with healthcare staff. The potential solutions identified for service providers would benefit from piloting and evaluation to help create a literacy-sensitive health service, which could improve engagement; enable self-care and enhance capabilities for health in those with low literacy.

Health literacy is demonstrated when individuals can obtain, process, and understand basic health information and services needed to make appropriate health decisions. Veteran health literacy is believed to be lower than the general population due to the aging and culturally diverse population. Veterans require adequate health literacy to manage their diverse high acuity physical injuries, psychological conditions, and chronic diseases. Clear communication between the clinician and veteran patient is essential to provide high quality health services. The objective of this quality-improvement project was to evaluate the ability of nurses in the ambulatory environment to identify low health literacy patients and to deliver an educational intervention focused on health literacy awareness and communication strategies. A pre-intervention Clear Communications Questionnaire (CCQ), a validated instrument, was delivered to 299 ambulatory nurses with a 20% response rate. The results from this questionnaire informed the development of a 40-minute educational program, multimedia and discussion format, provided to 200 nurses. Following the education program, the post-intervention CCQ was sent to the nurses, with a 30% response rate. Survey Monkey was utilized to collect the CCQ data and Minitab for the statistical analysis, including a pre- and post-intervention data analysis with a t test. While this project was unable to show a significant difference between the pre- and post-intervention CCQ, the individual survey items indicated increased awareness about the importance of health literacy and the ability to locate patient health literacy level in the medical record. Further work needs to be undertaken to assure veteran patients can actively engage in clear communication with clinicians, discern between treatment options, adhere to treatment recommendations, and develop health-seeking behaviors across their lifespans.

Disparities in medication adherence (MA) associated with African American (AA) adults may be related to a dynamic interplay between personal factors, behavioral capability, and environmental factors. The purpose of the study was to examine this relationship in AA adults with metabolic syndrome (MetS). A cross-sectional, correlational analysis was conducted from baseline data from a larger intervention study. Constructs from the Social Cognitive Theory were used to predict MA. The sample of 91 AA adults with MetS was primarily middle-aged (age range 45-70 years old; M 53, SD 6.3), female (79%), relatively well-educated, and married. Despite being on antihypertensive medications, 53% of the participants presented with uncontrolled high blood pressure (≥130/90 mmHg). Although the vast majority (95%) of the sample displayed adequate health literacy (HL), 30% of the sample was non-adherent to their medication regimen. A positive significant relationship was found between age and MA [χ2 (1, n = 90) = 6.71, p = .01)]. Stress [χ2 (1, n = 90) = 6.28, p = .012)] and social support (SS) [χ2 (1, n = 90) = 4.10, p = .04)] were the only significant relationships among environmental factors, barriers and hypertension MA. Highly stressed AA adults were significantly more likely to be non-adherent or had a 15% reduction in the odds of hypertension MA. Similarly, adults with a low income were 5.8 times more likely to be non-adherent (OR 5.828, 95% CI, 1.014-33.493, p= .0482), while those with low SS had a 9% reduction in the odds of MA; SS trended toward significance (OR.914. 95% CI .823-1.016, p =.09). With increasing age, AA adults were more likely to be non-adherent (OR 1.12, 95% CI 1.028-1.220, p =.0096). Most of the participants reported a high degree of autonomy, satisfaction with their health care climate, and the availability of SS. Although increasing age, adequate SS, high stress, and adequate HL appeared to influence MA in AA adults with MetS, the research questions were only partially answered. Further investigation of the relationships and potential mediating pathways between personal characteristics, environmental factors, behavioral capability and hypertension MA in AA adults with MetS is needed.

Health educators are expected to serve as resource of health knowledge and being e-health literate enable health educators to perform that function. However, the e-health literacy level of health education undergraduate students is rarely explored. A systematic literature review was conducted in order to investigate the e-health literacy levels of undergraduate students. The Research Readiness Self-Assessment-health (RRSA-h) was used to measure the ability of health education majors to find and evaluate electronic health information and a Q-study was conducted to investigate student characteristics that distinguish between those with high, middle, and low levels of e-health literacy. A convenience sample of 77 health education majors completed the RRSA-h. A MANOVA revealed that e-health literacy levels differed among classification level [F(4,140) = 2.597, p = .039]. Thirteen health education majors participated in the Q-study. An exploratory factor analysis revealed three types of e-health literate students exist among the majors. The literature revealed that college students have limited ability to find and evaluate electronic health information. The RRSA-h indicated that lower-level college students have less ability to find and evaluate e-health information than upper level students. The Q-study suggested that three types of health education majors exist and could be differentiated by their scores on the RRSA-h. The results of the study have implications for the development of instructional techniques to improve the e-health levels of health education majors. Specifically, the RRSA-h can be used to measure e-health literacy levels among health education majors and learning opportunities can be tailored to improve their e-health literacy levels.