Managing heart failure patients in the outpatient setting can pose a challenge for nurses and health care staff due to the need to educate patients on self-care skills and management of disease. Several factors, including health literacy and numeracy, need to be considered when developing an education program for heart failure patients to promote self-care management. The purpose of this project was to provide nursing staff with a clinical practice guideline (CPG) that incorporated health and numeracy literacy assessment into an individualized education program. The Johns Hopkins nursing evidence-based practice (EBP) model, the situation-specific theory of heart failure (HF) self-care, and Wagner's chronic care model guided the development and implementation of this project. The practice-focused question for this project asked whether evidence informs a CPG intended to assess health literacy and numeracy assessment and promote an enhanced individualized education intervention in an outpatient HF population. A literature review using 20 articles from 2006-2018 was completed. Five articles were selected to review levels of evidence, and three articles were chosen to support the development of the CPG. The CPG was reviewed, refined, and validated by an expert panel of HF nurses and physicians. The CPG might support a positive social change in the practice setting by improving the tools for nurses to assess health literacy in the HF patient population and provide individualized education to influence self-care interventions.

AUTHORS: Stella Chukwu DDS, Daniel Caplan, DDS, PhD, Michelle R. McQuistan, DDS, MS, Alice M. Horowitz, PhD, Christopher Squier PhD, Fang Qian, PhD TITLE: KNOWLEDGE OF RISK FACTORS FOR ORAL CANCER AMONG ADULT IOWANS OBJECTIVE: To gather baseline data from adult Iowans regarding their knowledge, opinions and practices about oral cancer (OC) prevention and early detection; with a focus on their knowledge of risk factors for OC. METHODS: A statewide, computer assisted random-digit dial telephone survey was conducted to gather information about OC prevention and early detection among Iowans age 18 and older. The survey contained 36 questions and lasted about ten minutes per respondent. Telephone numbers included landline and cell phone sampling lists provided by a private survey research firm. RESULTS: Of the 89 % of respondents that answered "yes" when asked if they had ever heard of OC, 54% had high OC risk factor knowledge; while of the eleven percent of those who said they had never heard of OC, 33% had high knowledge (p=0.003). Those that had an OC exam were more likely to have high OC risk factor knowledge (59%) compared with those that answered "no or don't know" to having had an OC exam (45%; p=0.002). Those that were "very or extremely" confident filling out medical forms were more likely to have high OC risk factor knowledge compared to respondents who were "not at all, slightly or moderately" confident filling out forms (54% vs. 45 %; p=0.097). CONCLUSIONS: The results suggest strongly that educational interventions are needed to increase knowledge of OC risk factors, early signs of OC, and the need to promote comprehensive OC examinations by healthcare providers. SOURCE OF FUNDING: Delta Dental of Iowa Foundation

The focus of this research was to: 1) study the perceptions of female students attending the university Student Health Center, concerning available services, 2) learn how they describe their decisions to obtain care, and 3) identify perceived barriers to reproductive health care and contraception. This exploratory study used a mixed-methods approach that included clinic public-space observations, interviews with health care providers and staff at Student Health Services (SHS), surveys distributed to clients of the campus clinic, and in-depth interviews to contextualize emergent themes. Topics addressed included sexual health behaviors and perceptions, influence of peers and partners, the propagation of health myths, and past experiences with SHS. Gathering practitioner perspectives on student barriers to care, goals of the clinic, and perceived health needs of the student community, allowed for measurement of incongruence between student and staff, thereby adding greater context to results. SHS sought recommendations in order to improve student's use of the Sexual Health and Gynecology clinic, increase accuracy of student's sexual health knowledge, and guide future clinic operations. SHS is now working with the College of Public Health to create improvement projects based on my results, including a peer education program. Research such as this can result in greater student awareness of available services, and more productive communication between patients and provide. Implications on the larger issues of gender and the search for health care, acceptance and knowledge of STI testing, and client comfort are addressed, and provide opportunity for future work in this area.

Health literacy affects caregivers' ability to engage in preventive health care behaviors for themselves and their children. Studies suggest that health literacy among low income families needs improvement, and this possibly contributes to disparities in preventive health care rates. Additionally, parents and caregivers may not be able to provide or seek preventive health care for their children because of lack of knowledge and skills to do so effectively. This study designed and piloted an intervention that delivered to parents of young children, 1) health literacy information in an experiential manner, and 2) practical skills to engage their families in healthy lifestyle choices, with the decisions for healthy lifestyle choices being based on the health knowledge provided in the intervention. Specifically, the intervention focused on diet/nutrition, physical activity, sleep hygiene, parenting skills, and mental wellness. The intervention was successful at improving diet/nutrition knowledge at least one month post-intervention and more immediate changes were found for participants' overall beliefs about diet/nutrition, children's vegetable consumption, and parents' fruits and vegetable consumption. Immediate improvements were also found for factual knowledge about physical activity, sleep, and the relationship between mental health and stress. Additionally, the intervention was successful at improving general knowledge and beliefs about sleep, knowledge about the relationship between sleep and health, and knowledge about common childhood sleep problems at least one month post-intervention. The intervention also reduced participants' bedtime interactions with children that are indicative of sleep problems at least one month post-intervention. Future research should conceptualize the intervention as a multiple health behavior intervention and reflect this in the evaluation.

Lack of patient adherence with medication results in health care costs and adverse clinical outcomes. Although fear of side effects can contribute to non-adherence, being informed about them can actually improve matters. Nonetheless, questions persist as to the most efficient way to convey that type of information to patients for a given medication. Information on side effects is largely limited to a simple list in medication leaflets, often without frequency data (that is, lacking detail as to how often they might occur). The decision-making literature suggests that the interpretation of information varies depending on the presentation format or the frame used. This study examined the impact of providing numerical information for side effect frequency, levels of illness severity, and side effect framing on the likelihood of taking an OTC medicine.<p> Participants received a headache scenario with three drug options (X, Y and Z) to consider for use. These painkillers had three levels of potency (defined as 50, 75, and 100% effective) and were accompanied with three levels of side effects (two, four, and six items). When considering their drug choice for the headaches, participants received drug information written without side effect frequency data, then again with side effect frequency data. Subjects rated their likelihood of taking Drug X, Y and Z on a scale of 1 (very unlikely) to 100 (very likely). Participants were also asked to show their likelihood of taking a different set of two medications for headaches (coined Drug N and P) based on positively-slanted or negatively-slanted wording in relation to chances of experiencing a side effect (heartburn).<p> Thirty subjects from Saskatoon over 50 years of age participated. The average age was 66.6 years and 63.3 percent of participants were female. Less than half of participants (n=11) had previous experience with side effects. Most participants were using at least one medicine (whether OTC or prescribed) and described themselves as knowledgeable or somewhat knowledgeable.<p> Participants were more likely to take the hypothetical drugs in the situations described when they received frequency data for side effects (p<0.05). Also, there was a significant higher mean likelihood of use when the drug was framed positively (p<0.01).<p> When considering decisions involving drug effectiveness and their side effects, the provision of frequency data increased patient likelihood of use. Framing the context in positive format also increased patient likelihood to use a medicine. This information could be important for pharmacists counseling on medication side effects, especially for those patients with medication adherence problems.

Introduction: The mass print media are a widely-distributed, and often primary, source of health information for the public. Health information in newspapers can amplify or attenuate readers’ perceptions of risk depending on how it is presented. This thesis examines how health information related to wind energy was communicated in Ontario newspapers and includes separate analyses for the presence of fright factors, readability, emergent themes, and emotional tone and sensationalism. As an emerging technology, public understanding of and response to associated health risks and uncertainties towards wind energy can be influenced by media coverage. Methods: Five geographically discontinuous wind energy installations in Ontario and their surrounding communities were selected based on 2006 Canadian Census data. Newspapers serving each community were identified and searched for articles from May 2007-April 2011 on the topic of health effects from wind energy developments. A total of 421 articles from 13 community and 4 national/provincial newspapers were retrieved. In Study #1, a directed content analysis was used to develop a coding instrument based on fright factors known to affect the public’s perception of risk. In Study #2, each newspaper article was analyzed for text readability using the Simple Measure of Gobbledygook (SMOG) readability formula. In Study #3, and as a qualitative component, a semi-directed content analysis was used to find emerging themes and subthemes. Finally, in Study #4, a list of loaded and positive words, informed from previous studies on sensationalism in media reporting and a random sample of newspaper articles included in this study, and the frequency of their appearance was used as a quantitative measure of sensationalism. Results: Study #1: The most commonly reported fright factors were ‘dread’, ‘poorly understood by science’, ‘involuntary exposure’, and ‘inequitable distribution’, occurring in 94% (n=394), 58% (n=242), 45% (n=188), and 42% (n=177) of articles, respectively. The fright factors of ‘dread’, ‘poorly understood by science’, ‘inequitable distribution’, and ‘inescapable exposure’ occurred more frequently in community newspaper articles than in national/provincial ones (p<0.001). Although the total number of occurrences of each fright factor increased following the Green Energy Act, only ‘dread’ (p<0.05) and ‘poorly understood by science’ (p<0.01) increased significantly. Study #2: The mean reading grade level (RGL) of 421 articles on wind turbines and health was at the post-secondary education level (X±SEM; 13.3±0.1). Articles from community and provincial newspapers were written at almost a full RGL lower (13.2±0.2 and 13.1±0.2) than those from national newspapers (13.9±0.2) (p<0.05). Additionally, opinion pieces such as editorial columns were written at a lower RGL than fact-based news articles (13.0±0.2 and 13.5±0.1, respectively; p<0.01). Study #3: The majority of newspaper articles described health effects of wind turbines in general, rather than specific, terms. The most commonly cited causes of health complaints were inadequate setbacks (27%, n=114), noise (21%, n=90), shadow flicker and vibrations (12%, n=49), and electrical exposure (6%, n=27). Other, non-health concerns such as environmental damage (28%, n=117), property values (20%, n=86), aesthetic concerns (18%, n=77), financial burden (18%, n=74), were prevalent and juxtaposed with health issues in 28% of articles (n=118). Concerns with the quality and availability of scientific evidence were frequent in the newspaper articles (34%, n=143), with many articles promoting a moratorium on wind energy developments until further research is conducted (25%, n=103). Study #4: Newspaper articles emphasized negative rather than positive/neutral tone, with community newspapers publishing a higher proportion of negative articles than provincial or national newspapers (X2=6.11, df=1, p<0.05). Conclusion: These findings suggest that the health information related to wind turbines in Ontario newspapers contains a large quantity of fright factors that may produce fear and anxiety in readers, is written at a reading grade level that is too complex for the majority of the Ontario population to fully understand, contains inconsistent information on health effects that often links health concerns with non-health concerns, and is often negative in tone. The influence of the Ontario newspaper media on reader’s risk perceptions of wind energy in Ontario will be important to determine empirically.

This study analyses warehoused data collected by Georgia State University and Centers for Disease Control and Prevention (GSU/CDC) researchers after developing an HIV testing message for urban adults with low functional health literacy. It expands previous work by examining data collected when 202 primarily African-American homeless clients of an urban community based organization (CBO) reviewed both the low literacy brochure (Wallace et. al., 2006) and a standard HIV brochure (Georgia Department of Human Resources, 1997). Participants’ health literacy was assessed using 2 measures; the Rapid Estimate of Adult Literacy in Medicine or REALM (Davis, Crouch, Long & Green) and the Test of Functional Health Literacy Assessment or TOFHLA (Nurss, Parker & Baker, 2001). HIV risk was determined using an interview questionnaire developed by the research group (Belcher, Deming, Hunter & Wallace, 2005) which allowed participants to self-report recent alcohol and drug use, sexual behavior, sexually transmitted disease (STD) history and exposure to abuse and sexual coercion. Open-ended response questions regarding readability, understanding, main message, and importance for each brochure provided the qualitative data.This analysis confirms previous work showing accessibility, readability, cultural sensitivity and user-friendly formatting are important when attempting to engage at-risk adults with varying levels of functional health literacy in an HIV testing message. The visual aspects of the brochure can be essential in capturing the reader’s attention and should be relevant to the target audience (Wallace, Deming, Hunter, Belcher & Choi, 2006). Mono-colored graphics may be perceived as dated and irrelevant or worse yet, threatening to some readers. Whenever possible culturally appropriate color photos of people depicting relevant content should replace excess text and difficult medical terms should be eliminated. Wording on the cover and within the brochure should be used to focus the reader on a single main message.This data also shows that many participants considered the quantity of information just as important. For reasons not elucidated here, many respondents equated quantity of information with message quality. Based on these results it is important to further clarify how much information is enough to maintain legitimacy and the reader’s attention while simultaneously avoiding confusing mixed messages.

The prevalence of hypertension (HTN) is high in Latinos (Latino/Latina) Americans due to social and ecological factors. Increased migration of Latino migrant/seasonal farmworkers (MSFW) to the U.S. augments the social, economic, environmental, and psychosocial factors associated with health and illness. Bronfenbrenner’s Ecological Systems Theory was used to guide this study. The purposes of this cross-sectional, correlational study were to explore Latino MSFWs’ adherence to HTN treatment (medication adherence, blood pressure [BP] self-care, and BP control) and to examine the influence of BP knowledge, perceived stress, acculturation, health literacy, and health care access (HCA) on adherence to HTN treatment. A total of 45 Latino (mean age 45 + 9) MSFWs receiving HTN treatment participated in this study. Spanish and English questionnaires were available for participants to measure adherence to HTN treatment and the five independent variables. Analysis included correlations, t-tests, hierarchical multiple regression, and hierarchical logistic regression. The majority of MSFWs were from Mexico, female (55.6%), had less than a 6th grade education. Most (82%) of the MSFWs had uncontrolled BP, and were not adherent to medications (42%), even with high BP knowledge scores (M = 6.5 ±1.3). MSFWs perceived a high level of stress (M = 16 + 6.9), low acculturation level (Anglo orientation: M = 2.9 + 0.9), and no employer-provided health insurance for personal illnesses or injuries (93%). Blood pressure knowledge, perceived stress, acculturation, health literacy, and HCA accounted for 49% of the variance in the BP self-care; however, only higher BP knowledge was a significant predictor of better BP self-care (p < .001). Furthermore, acculturation was a significant predictor of BP control (p < .01). This study explored select determinants of adherence to HTN treatment in Latino MSFWs in a culturally informed way. Although BP self-care behaviors appeared to be a consequence of BP knowledge, this study found low medication adherence in Latino MSFWs and uncontrolled BP explained by the two predictors, acculturation and health literacy. Perceived stress and health care access did not influence the adherence to HTN treatment. MSFWs had poor BP control and HTN treatment adherence. A culturally appropriate educational program is needed to help the MSFWs adherence to HTN treatment.

Introduction: Colon cancer is the third leading cause of cancer death among women in Canada. Although regular screening beginning at age 50 years can significantly decrease risk of colon cancer mortality, many eligible Canadian women have never obtained screening. Cancer screening rates among immigrant women to Canada are even lower than for native-born women. Disparities in the use of preventive cancer services by immigrants have been linked to limited acculturation and speaking a language other than English. Poor prose comprehension may frustrate access and use of preventive cancer information by older ESL immigrant women to Canada. In order to develop useful and actionable cancer prevention information, it is necessary to understand the barriers ESL immigrant women face in obtaining and using health and cancer information. Therefore, the primary objective of this research was to assess the relationship of acculturation on the prose comprehension of older ESL immigrant women to Canada. Methods: Interviews were conducted with 78 older adult Spanish-speaking immigrant women (aged 45 to 73 years) residing in Kitchener-Waterloo, Ontario. Acculturation was inferred by length of Canadian residency and measured using the Bidimensional Acculturation Scale (BAS). Several measures were used to assess comprehension including the shortened Test of Functional Health Literacy in Adults (S-TOFHLA), the Rapid Estimate of Literacy in Medicine (REALM), the Newest Vital Sign (NVS), and a modified Cloze procedure. The modified Cloze procedure was constructed using a one-page colon cancer information sheet created for the public by the Canadian Cancer Society. Four multiple linear regression analyses were used to test the relationship between the independent variables of acculturation (BAS) and length of Canadian residency, age, Spanish language education, employment, and media variables (television and internet use) on each measure of prose comprehension (i.e., dependent variables of scores on S-TOFHLA, NVS, REALM and Cloze). Logistic regression was used to test whether acculturation and comprehension predicted screening intentions. Semi-structured interviews were conducted to identify the women’s cancer information needs and preferences as well as the barriers they experienced in obtaining and understanding English language cancer information. Results: Three significant models predicting comprehension of colon cancer and health information were identified. The independent variables BAS, Spanish language education and television viewing explained 23% of the variation in Cloze comprehension scores (F=6.76; df=3; p < 0.01; R2= 0.23). Approximately 42% of the variation in S-TOFHLA scores among older ESL immigrant women was explained by the independent variables BAS, age, television viewing and internet use (F=12.13; df=5; p < 0.01; R2=0.42). Using REALM as the dependent measure of comprehension, BAS and television viewing explained 17% of the variation in scores (F=7.54; df=2; p<0.01; R2=0.17). BAS was the only significant predictor of the dependent comprehension measure NVS (F=5.36; df=1; p=0.02; R2=0.07). Logistic regression models predicting colon cancer screening intentions were not significant. Qualitative data analyses revealed that women’s colon cancer information needs, preferences and perceived barriers accessing English language information did not vary according to BAS score or duration of residency in Canada. All women requested actionable information that was community and culturally specific. Additional factors related to older ESL immigrant women’s comprehension of cancer information were identified. These included self-efficacy, social networks and mode of information delivery. These additional modes of information delivery included receiving health information orally as compared to written information. Conclusion: Acculturation (as measured by BAS) significantly predicted prose comprehension by older ESL Spanish speaking immigrant women across four separate measurement tools (Cloze, S-TOFHLA, REALM, NVS). Yet, the proportion of the variance in comprehension scores explained by acculturation and other demographic variables was low to modest, ranging from 7-42%. In addition to acculturation, self-efficacy and social networks may also be associated with prose comprehension. Low self-efficacy among older ESL immigrant women may be a barrier to information seeking and perceived comprehension. However, strong social networks may provide women with the confidence and resources necessary to access health information and services. These results highlight the need for the additional research regarding the influence of self-efficacy on ESL immigrants’ ability to find and use health and cancer information. Recommendations: This research has important implications for public health educators. Health educators are encouraged to develop cancer and health information for ESL speakers in Canada that is community, culturally and linguistically specific and which provides actionable information. This is especially salient given the changing demographic and cultural profile of Canadians. Also, among older ESL immigrants who struggle with language barriers, receiving health information orally may be preferred.

Introduction: Colon cancer incidence and mortality rates in Canada are among the highest worldwide. If detected early colon cancer is highly curable and regular screening can significantly decrease risk of colon cancer mortality. Despite this, screening rates in Canada are consistently low and immigrant and senior populations are particularly vulnerable due to low health literacy and language barriers. This research consists of three studies that were designed to explore the cancer prevention experiences of older English-as-a-Second Language (ESL) Chinese immigrant women in Canada. This includes an investigation of colon and breast cancer screening utilization, health literacy skills and comprehension of colon cancer prevention information, and experiences and preferences when seeking cancer information by these immigrant women. Methods: A convenience sample of 110 Mandarin and Cantonese-speaking ESL immigrant women were recruited from two Southern Ontario communities. For study inclusion participants were required to: (1) be 50 years of age or older, (2) have immigrated to Canada, (3) have Cantonese or Mandarin as their first language and English as their second language, and (4) be able to read in English. Participants were excluded if they or their spouse had been previously diagnosed with any type of cancer. Participants completed a battery of questionnaires assessing demographic characteristics, use of breast and colon cancer screening, acculturation, self-efficacy, health beliefs and health literacy. Health literacy was assessed using the Short Test of Functional Health Literacy in Adults (S-TOFHLA) and comprehension of a colon cancer prevention information sheet from Cancer Care Ontario was assessed using the cloze procedure. Participants participated in a semi-structured interview to explore cancer information seeking preferences and experiences, and their understanding of cancer prevention information. Multivariate logistic regression was used to identify predictors of colon and breast cancer screening. To identify variables significantly associated with performance on the S-TOFHLA and cloze test regression analyses were performed. Directed content analysis was used to identify themes associated with barriers to cancer information seeking and understanding that emerged from the interviews. Results: Study #1: There was high self-reported screening for breast and colon cancer. Eighty-five percent of the women were current mammography screeners and 75% were current colon cancer screeners. Recommendation from a physician (OR=.140; 95% CI= .044, -.448), having a female physician (OR=.141; 95% CI= .033, .591), and high or moderate proficiency in English (OR=.283; 95% CI= .089, .902) significantly predicted mammography screening. Physician recommendation (OR=.103; 95% CI= .031, .349), first language (OR= 1.85; 95% CI= .055, .628) and higher self-efficacy (OR= 3.613; 95% CI= 1.179, 11.070) predicted use of colon cancer screening. Other important predictors included greater health literacy and longer residency in Canada. Study #2: Only 38.7% of the women had adequate health literacy on S-TOFHLA and 54.3% had adequate comprehension of the colon cancer information. Comprehension of the colon cancer information was significantly lower among women who received the information in English, compared to those who received the information in Chinese (p<0.01). Age, acculturation, self-reported proficiency reading English, and education were significant predictors of health literacy but varied depending on the measure (S-TOFHLA, cloze) and language of information (English, Chinese). Study #3: There were unique health information seeking preferences among the older Chinese immigrant women including a strong preference for interpersonal and interactive cancer information from their physician and trusted others, such as friends and family. Barriers to cancer information seeking included language difficulties and limited time with physicians. Differences in health literacy did not distinguish the women on any of the major themes. Conclusion: Language, culture, health literacy and the role of the physician emerged across all three studies examining the cancer prevention experiences of older Chinese immigrant women. While language concordant educational materials may improve understanding of cancer information, the results from this study suggest that it is important to consider factors other than language alone and to address important cultural issues that play a role in the access, use, and understanding of cancer information.