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1.  The Effectiveness of Mobile-Health Technology-Based Health Behaviour Change or Disease Management Interventions for Health Care Consumers: A Systematic Review 
PLoS Medicine  2013;10(1):e1001362.
Caroline Free and colleagues systematically review a fast-moving field, that of the effectiveness of mobile technology interventions delivered to healthcare consumers, and conclude that high-quality, adequately powered trials of optimized interventions are required to evaluate effects on objective outcomes.
Background
Mobile technologies could be a powerful media for providing individual level support to health care consumers. We conducted a systematic review to assess the effectiveness of mobile technology interventions delivered to health care consumers.
Methods and Findings
We searched for all controlled trials of mobile technology-based health interventions delivered to health care consumers using MEDLINE, EMBASE, PsycINFO, Global Health, Web of Science, Cochrane Library, UK NHS HTA (Jan 1990–Sept 2010). Two authors extracted data on allocation concealment, allocation sequence, blinding, completeness of follow-up, and measures of effect. We calculated effect estimates and used random effects meta-analysis. We identified 75 trials. Fifty-nine trials investigated the use of mobile technologies to improve disease management and 26 trials investigated their use to change health behaviours. Nearly all trials were conducted in high-income countries. Four trials had a low risk of bias. Two trials of disease management had low risk of bias; in one, antiretroviral (ART) adherence, use of text messages reduced high viral load (>400 copies), with a relative risk (RR) of 0.85 (95% CI 0.72–0.99), but no statistically significant benefit on mortality (RR 0.79 [95% CI 0.47–1.32]). In a second, a PDA based intervention increased scores for perceived self care agency in lung transplant patients. Two trials of health behaviour management had low risk of bias. The pooled effect of text messaging smoking cessation support on biochemically verified smoking cessation was (RR 2.16 [95% CI 1.77–2.62]). Interventions for other conditions showed suggestive benefits in some cases, but the results were not consistent. No evidence of publication bias was demonstrated on visual or statistical examination of the funnel plots for either disease management or health behaviours. To address the limitation of the older search, we also reviewed more recent literature.
Conclusions
Text messaging interventions increased adherence to ART and smoking cessation and should be considered for inclusion in services. Although there is suggestive evidence of benefit in some other areas, high quality adequately powered trials of optimised interventions are required to evaluate effects on objective outcomes.
Please see later in the article for the Editors' Summary
Editors’ Summary
Background
Every year, millions of people die from cardiovascular diseases (diseases of the heart and circulation), chronic obstructive pulmonary disease (a long-term lung disease), lung cancer, HIV infection, and diabetes. These diseases are increasingly important causes of mortality (death) in low- and middle-income countries and are responsible for nearly 40% of deaths in high-income countries. For all these diseases, individuals can adopt healthy behaviors that help prevent disease onset. For example, people can lower their risk of diabetes and cardiovascular disease by maintaining a healthy body weight, and, if they are smokers, they can reduce their risk of lung cancer and cardiovascular disease by giving up cigarettes. In addition, optimal treatment of existing diseases can reduce mortality and morbidity (illness). Thus, in people who are infected with HIV, antiretroviral therapy delays the progression of HIV infection and the onset of AIDS, and in people who have diabetes, good blood sugar control can prevent retinopathy (a type of blindness) and other serious complications of diabetes.
Why Was This Study Done?
Health-care providers need effective ways to encourage "health-care consumers" to make healthy lifestyle choices and to self-manage chronic diseases. The amount of information, encouragement and support that can be conveyed to individuals during face-to-face consultations or through traditional media such as leaflets is limited, but mobile technologies such as mobile phones and portable computers have the potential to transform the delivery of health messages. These increasingly popular technologies—more than two-thirds of the world's population now owns a mobile phone—can be used to deliver health messages to people anywhere and at the most relevant times. For example, smokers trying to quit smoking can be sent regular text messages to sustain their motivation, but can also use text messaging to request extra support when it is needed. But is "mHealth," the provision of health-related services using mobile communication technology, an effective way to deliver health messages to health-care consumers? In this systematic review (a study that uses predefined criteria to identify all the research on a given topic), the researchers assess the effectiveness of mobile technology-based health behavior change interventions and disease management interventions delivered to health-care consumers.
What Did the Researchers Do and Find?
The researchers identified 75 controlled trials (studies that compare the outcomes of people who do and do not receive an intervention) of mobile technology-based health interventions delivered to health-care consumers that met their predefined criteria. Twenty-six trials investigated the use of mobile technologies to change health behaviors, 59 investigated their use in disease management, most were of low quality, and nearly all were undertaken in high-income countries. In one high-quality trial that used text messages to improve adherence to antiretroviral therapy among HIV-positive patients in Kenya, the intervention significantly reduced the patients’ viral load but did not significantly reduce mortality (the observed reduction in deaths may have happened by chance). In two high-quality UK trials, a smoking intervention based on text messaging (txt2stop) more than doubled biochemically verified smoking cessation. Other lower-quality trials indicated that using text messages to encourage physical activity improved diabetes control but had no effect on body weight. Combined diet and physical activity text messaging interventions also had no effect on weight, whereas interventions for other conditions showed suggestive benefits in some but not all cases.
What Do These Findings Mean?
These findings provide mixed evidence for the effectiveness of health intervention delivery to health-care consumers using mobile technologies. Moreover, they highlight the need for additional high-quality controlled trials of this mHealth application, particularly in low- and middle-income countries. Specifically, the demonstration that text messaging interventions increased adherence to antiretroviral therapy in a low-income setting and increased smoking cessation in a high-income setting provides some support for the inclusion of these two interventions in health-care services in similar settings. However, the effects of these two interventions need to be established in other settings and their cost-effectiveness needs to be measured before they are widely implemented. Finally, for other mobile technology–based interventions designed to change health behaviors or to improve self-management of chronic diseases, the results of this systematic review suggest that the interventions need to be optimized before further trials are undertaken to establish their clinical benefits.
Additional Information
Please access these Web sites via the online version of this summary at http://dx.doi.org/10.1371/journal.pmed.1001362.
A related PLOS Medicine Research Article by Free et al. investigates the ability of mHealth technologies to improve health-care service delivery processes
Wikipedia has a page on mHealth (note: Wikipedia is a free online encyclopedia that anyone can edit; available in several languages)
mHealth: New horizons for health through mobile technologies is a global survey of mHealth prepared by the World Health Organization’s Global Observatory for eHealth (eHealth is health-care practice supported by electronic processes and communication)
The mHealth in Low-Resource Settings website, which is maintained by the Netherlands Royal Tropical Institute, provides information on the current use, potential, and limitations of mHealth in low-resource settings
More information about Txt2stop is available, the UK National Health Service Choices website provides an analysis of the Txt2stop trial and what its results mean, and the UK National Health Service Smokefree website provides a link to a Quit App for the iPhone
The US Centers for Disease Control and Prevention has launched a text messaging service that delivers regular health tips and alerts to mobile phones
doi:10.1371/journal.pmed.1001362
PMCID: PMC3548655  PMID: 23349621
2.  Different patient subgroup, different ranking? Which quality indicators do patients find important when choosing a hospital for hip- or knee arthroplasty? 
Background
Patients are increasingly expected to become active, critical consumers in healthcare. They can use comparative healthcare information presented on websites to make informed choices for healthcare providers. However, the use of this information has been limited so far. An obstacle can be that the information is not perceived as relevant by patients. Presenting only the most important quality indicators might improve the usefulness of this information. The aim of this study was to explore which quality indicators different subgroups of patients find important when choosing a hospital for total hip arthroplasty (THA) or total knee arthroplasty (TKA).
Methods
In this explorative, cross-sectional study, questionnaires were distributed to 265 patients who underwent or had to undergo THA/TKA. Participants were asked to rank the importance of three types of quality indicators: patient experience indicators, clinical performance indicators, and indicators about hospital services. We used random effects regression analyses to assess the relative importance of the indicators in different subgroups of patients.
Results
110 patients (response rate 41.5%) who underwent or had to undergo THA/TKA participated. Conduct of doctors, the presence of procedures to prevent adverse effects of thrombosis and information about the specialist area of orthopaedists were the most important patient experience indicator, clinical performance indicator and indicator about hospital services, respectively. We found a few differences between patient subgroups in the importance attached to the quality indicators.
Conclusions
This study provides a first insight into which quality indicators patients find important when choosing a hospital for THA/TKA, and shows that subgroups of patients differ in the value they attach to these indicators. More extended research is needed to establish the indicators that should at least be presented in succinct overviews of comparative healthcare information for patients choosing a hospital for THA/TKA.
doi:10.1186/1472-6963-11-299
PMCID: PMC3268112  PMID: 22050686
3.  Public release of performance data in changing the behaviour of healthcare consumers, professionals or organisations 
Background
It is becoming increasingly common to release information about the performance of hospitals, health professionals or providers, and healthcare organisations into the public domain. However, we do not know how this information is used and to what extent such reporting leads to quality improvement by changing the behaviour of healthcare consumers, providers and purchasers, or to what extent the performance of professionals and providers can be affected.
Objectives
To determine the effectiveness of the public release of performance data in changing the behaviour of healthcare consumers, professionals and organisations.
Search methods
We searched the Cochrane Central Register of Controlled Trials (CENTRAL), Cochrane Effective Practice and Organisation of Care (EPOC) Trials Register, MEDLINE Ovid (from 1966), EMBASE Ovid (from 1979), CINAHL, PsycINFO Ovid (from 1806) and DARE up to 2011.
Selection criteria
We searched for randomised or quasi-randomised trials, interrupted time series and controlled before-after studies of the effects of publicly releasing data regarding any aspect of the performance of healthcare organisations or individuals. The papers had to report at least one main outcome related to selecting or changing care. Other outcome measures were awareness, attitude, views and knowledge of performance data and costs.
Data collection and analysis
Two review authors independently screened studies for eligibility and extracted data. For each study, we extracted data about the target groups (healthcare consumers, healthcare providers and healthcare purchasers), performance data, main outcomes (choice of healthcare provider and improvement by means of changes in care) and other outcomes (awareness, attitude, views, knowledge of performance data and costs).
Main results
We included four studies containing more than 35,000 consumers, and 1560 hospitals. Three studies were conducted in the USA and examined consumer behaviour after the public release of performance data. Two studies found no effect of Consumer Assessment of Healthcare Providers and Systems information on health plan choice in a Medicaid population. One interrupted time series study found a small positive effect of the publishing of data on patient volumes for coronary bypass surgery and low-complication outliers for lumbar discectomy, but these effects did not persist longer than two months after each public release. No effects on patient volumes for acute myocardial infarction were found.
One cluster-randomised controlled trial, conducted in Canada, studied improvement changes in care after the public release of performance data for patients with acute myocardial infarction and congestive heart failure. No effects for the composite process-of-care indicators for either condition were found, but there were some improvements in the individual process-of-care indicators. There was an effect on the mortality rates for acute myocardial infarction. More quality improvement activities were initiated in response to the publicly-released report cards. No secondary outcomes were reported.
Authors’ conclusions
The small body of evidence available provides no consistent evidence that the public release of performance data changes consumer behaviour or improves care. Evidence that the public release of performance data may have an impact on the behaviour of healthcare professionals or organisations is lacking.
doi:10.1002/14651858.CD004538.pub2
PMCID: PMC4204393  PMID: 22071813
*Information Dissemination; *Quality Improvement; Canada; Consumer Health Information [*methods]; Evaluation Studies as Topic; Health Maintenance Organizations [standards]; Hospitals [*standards]; Medicaid; Organizational Innovation; Quality Assurance, Health Care [*methods]; Randomized Controlled Trials as Topic; Reproducibility of Results; United States; Humans
4.  How do Consumers Search for and Appraise Information on Medicines on the Internet? A Qualitative Study Using Focus Groups 
Background
Many consumers use the Internet to find information about their medicines. It is widely acknowledged that health information on the Internet is of variable quality and therefore the search and appraisal skills of consumers are important for selecting and assessing this information. The way consumers choose and evaluate information on medicines on the Internet is important because it has been shown that written information on medicines can influence consumer attitudes to and use of medicines.
Objective
To explore consumer experiences in searching for and appraising Internet-based information on medicines.
Methods
Six focus groups (N = 46 participants) were conducted in metropolitan Sydney, Australia from March to May 2003 with consumers who had used the Internet for information on medicines. Verbatim transcripts of the group discussions were analyzed using a grounded theory approach.
Results
All participants reported using a search engine to find information on medicines. Choice of search engine was determined by factors such as the workplace or educational environments, or suggestions by family or friends. Some participants found information solely by typing the medicine name (drug or brand name) into the search engine, while others searched using broader terms. Search skills ranged widely from more-advanced (using quotation marks and phrases) to less-than-optimal (such as typing in questions and full sentences). Many participants selected information from the first page of search results by looking for keywords and descriptions in the search results, and by looking for the source of the information as apparent in the URL. Opinions on credible sources of information on medicines varied with some participants regarding information by pharmaceutical companies as the "official" information on a medicine, and others preferring what they considered to be impartial sources such as governments, organizations, and educational institutions. It was clear that although most participants were skeptical of trusting information on the Internet, they had not paid conscious attention to how they selected information on medicines. Despite this, it was evident that participants viewed the Internet as an important source for information on medicines.
Conclusions
The results showed that there was a range of search and appraisal skills among participants, with many reporting a limited awareness of how they found and evaluated Internet-based information on medicines. Poor interpretation of written information on medicines has been shown to lead to anxiety and poor compliance to therapy. This issue is more important for Internet-based information since it is not subject to quality control and standardization as is written information on medicines. Therefore, there is a need for promoting consumer search and appraisal skills when using this information. Educating consumers in how to find and interpret Internet-based information on medicines may help them use their medicines in a safer and more-effective way.
doi:10.2196/jmir.5.4.e33
PMCID: PMC1550579  PMID: 14713661
Medicines; drugs; information; Internet; consumers; focus groups; qualitative research
5.  Development of a Medicare Beneficiary Comprehension Test: Assessing Medicare Part D Beneficiaries' Comprehension of Their Benefits 
American Health & Drug Benefits  2013;6(8):453-461.
Background
Medicare Part D, the senior prescription drug benefit plan, was introduced through the Medicare Modernization Act of 2003. Medicare beneficiaries receive information about plan options through multiple sources, and it is often assumed by consumer health plans and healthcare providers that beneficiaries can understand and compare plan information. Medicare beneficiaries are older, may have cognitive problems, and may not have a true understanding of managed care. They are more likely than younger persons to have inadequate health literacy, thereby demonstrating significant gaps in knowledge and information about healthcare.
Objective
To develop a Medicare Beneficiary Comprehension Test (MBCT) to evaluate Medicare beneficiaries' understanding of Part D plan concepts, as presented in the 2008 Medicare & You handbook.
Methods
A 10-question MBCT was developed using a case-vignette approach that required beneficiaries to read portions of the Medicare & You handbook and answer Part D–related questions associated with healthcare decision-making. The test was divided into 2 sections: (I) insurance concepts and (II) utilization management/appeals and grievances to cover standard terminology, as well as newer utilization management and appeals and grievances procedures that are unique to Part D. The test was administered to 100 beneficiaries at 2 sites—a university geriatrics clinic and a private retirement facility. Beneficiaries were tested for cognition and health literacy before being administered the test.
Results
The mean score on the MBCT was 3.5 of a maximum of 5, with no statistical difference found between both sites. Ten faculty members and 4 graduate students assessed the content validity of the instrument using a 4-point Likert rating rubric. The construct validity of the instrument was assessed using a principal components analysis with varimax rotation. The principal components analysis yielded 4 factors that were labeled as “Plan D concepts,” “managed care/utilization management,” “cost-sharing,” and “plan comparisons.” The factor analysis indicated that the test is multidimensional and did measure the construct.
Conclusions
Medicare beneficiaries' understanding of Part D may play a key role in the management of their drug use and health and the associated outcomes. The MBCT and its pending revisions can be administered to beneficiaries with differing health outcomes. Medicare beneficiaries are often faced with several pieces of information involving a complex array of choices amidst bewildering plan options. It is crucial that beneficiaries and/or their family members involved in the decision-making process understand the plan benefits to truly make an informed decision. As the number of Medicare beneficiaries increases over the coming years with the baby boomers, it becomes even more imperative that the elderly have improved access to treatments that can achieve desirable outcomes. Measuring comprehension by Medicare beneficiaries may be an initial step toward understanding more complex issues, such as treatment adherence, decision-making, and, ultimately, trends in healthcare utilization and outcomes.
PMCID: PMC4031733  PMID: 24991375
6.  Impact of Patients’ Judgment Skills on Asthma Self-Management: A Pilot Study 
Background
The majority of current health literacy tools assess functional skills including reading, writing, and numeracy. Although these tools have been able to underline the impact of such skills on individuals’ health behaviour, there is a need for comprehensive measures to examine more advanced skills. The individual’s ability to use health-related information considering his/her own health context, and judging positive and negative consequences of their decisions has been conceptualized as judgment skills. The present study used a newly developed judgment skills tool to explore asthma self-management practices.
Design and methods
Eighty asthma patients were recruited from medical offices during the year 2013. The questionnaire was self-administered and contained health literacy questions, the judgment skill tool, the Asthma Control Test, and several self-management questions.
Results
Sixty-nine percent of participants had adequate health literacy, while 24% and 5% had marginal and inadequate levels, respectively. The high-judgment group referred more to their doctor when experiencing asthma problems t(76)=–2.18, P<0.032; complied more with the use of their control medicine t(77)=–3.24, P<0.002 and went more regularly to the doctor t(78)=–1.80, P<0.038 (one-tailed) than the low-judgment group.
Conclusions
The judgment skills tool can help identify asthma patients’ health information use and reveal how this use may affect some self-management practices.
Significance for public healthPatients’ health literacy has a great impact on their health behaviours and their health outcomes. Therefore, it has become more and more common to measure health literacy within the healthcare setting to determine the most effective approach to target patients. The measurement of asthma judgment skills contribute to a deeper understanding of patients’ asthma self-management in crucial topics for asthma control, and have the advantage of assessing the specific abilities needed for this particular condition, which in turn benefits the translation of the findings from the use of this tool into strategies that directly tackle the needs of asthma patients.
doi:10.4081/jphr.2014.307
PMCID: PMC4274496  PMID: 25553312
health literacy; judgment skills; asthma self-management; pilot study
7.  Associations between Stroke Mortality and Weekend Working by Stroke Specialist Physicians and Registered Nurses: Prospective Multicentre Cohort Study 
PLoS Medicine  2014;11(8):e1001705.
In a multicenter observational study, Benjamin Bray and colleagues evaluate whether weekend rounds by stroke specialist physicians, or the ratio of registered nurses to beds on weekends, is associated with patient mortality after stroke.
Please see later in the article for the Editors' Summary
Background
Observational studies have reported higher mortality for patients admitted on weekends. It is not known whether this “weekend effect” is modified by clinical staffing levels on weekends. We aimed to test the hypotheses that rounds by stroke specialist physicians 7 d per week and the ratio of registered nurses to beds on weekends are associated with mortality after stroke.
Methods and Findings
We conducted a prospective cohort study of 103 stroke units (SUs) in England. Data of 56,666 patients with stroke admitted between 1 June 2011 and 1 December 2012 were extracted from a national register of stroke care in England. SU characteristics and staffing levels were derived from cross-sectional survey. Cox proportional hazards models were used to estimate hazard ratios (HRs) of 30-d post-admission mortality, adjusting for case mix, organisational, staffing, and care quality variables. After adjusting for confounders, there was no significant difference in mortality risk for patients admitted to a stroke service with stroke specialist physician rounds fewer than 7 d per week (adjusted HR [aHR] 1.04, 95% CI 0.91–1.18) compared to patients admitted to a service with rounds 7 d per week. There was a dose–response relationship between weekend nurse/bed ratios and mortality risk, with the highest risk of death observed in stroke services with the lowest nurse/bed ratios. In multivariable analysis, patients admitted on a weekend to a SU with 1.5 nurses/ten beds had an estimated adjusted 30-d mortality risk of 15.2% (aHR 1.18, 95% CI 1.07–1.29) compared to 11.2% for patients admitted to a unit with 3.0 nurses/ten beds (aHR 0.85, 95% CI 0.77–0.93), equivalent to one excess death per 25 admissions. The main limitation is the risk of confounding from unmeasured characteristics of stroke services.
Conclusions
Mortality outcomes after stroke are associated with the intensity of weekend staffing by registered nurses but not 7-d/wk ward rounds by stroke specialist physicians. The findings have implications for quality improvement and resource allocation in stroke care.
Please see later in the article for the Editors' Summary
Editors' Summary
Background
In a perfect world, a patient admitted to hospital on a weekend or during the night should have as good an outcome as a patient admitted during regular working hours. But several observational studies (investigations that record patient outcomes without intervening in any way; clinical trials, by contrast, test potential healthcare interventions by comparing the outcomes of patients who are deliberately given different treatments) have reported that admission on weekends is associated with a higher mortality (death) rate than admission on weekdays. This “weekend effect” has led to calls for increased medical and nursing staff to be available in hospitals during the weekend and overnight to ensure that the healthcare provided at these times is of equal quality to that provided during regular working hours. In the UK, for example, “seven-day working” has been identified as a policy and service improvement priority for the National Health Service.
Why Was This Study Done?
Few studies have actually tested the relationship between patient outcomes and weekend physician or nurse staffing levels. It could be that patients who are admitted to hospital on the weekend have poor outcomes because they are generally more ill than those admitted on weekdays. Before any health system introduces potentially expensive increases in weekend staffing levels, better evidence that this intervention will improve patient outcomes is needed. In this prospective cohort study (a study that compares the outcomes of groups of people with different baseline characteristics), the researchers ask whether mortality after stroke is associated with weekend working by stroke specialist physicians and registered nurses. Stroke occurs when the brain's blood supply is interrupted by a blood vessel in the brain bursting (hemorrhagic stroke) or being blocked by a blood clot (ischemic stroke). Swift treatment can limit the damage to the brain caused by stroke, but of the 15 million people who have a stroke every year, about 6 million die within a few hours and another 5 million are left disabled.
What Did the Researchers Do and Find?
The researchers extracted clinical data on 56,666 patients who were admitted to stroke units in England over an 18-month period from a national stroke register. They obtained information on the characteristics and staffing levels of the stroke units from a biennial survey of hospitals admitting patients with stroke, and information on deaths among patients with stroke from the national register of deaths. A quarter of the patients were admitted on a weekend, almost half the stroke units provided stroke specialist physician rounds seven days per week, and the remainder provided rounds five days per week. After adjustment for factors that might have affected outcomes (“confounders”) such as stroke severity and the level of acute stroke care available in each stroke unit, there was no significant difference in mortality risk between patients admitted to a stroke unit with rounds seven days/week and patients admitted to a unit with rounds fewer than seven days/week. However, patients admitted on a weekend to a stroke unit with 1.5 nurses/ten beds had a 30-day mortality risk of 15.2%, whereas patients admitted to a unit with 3.0 nurses/ten beds had a mortality risk of 11.2%, a mortality risk difference equivalent to one excess death per 25 admissions.
What Do These Findings Mean?
These findings show that the provision of stroke specialist physician rounds seven days/week in stroke units in England did not influence the (weak) association between weekend admission for stroke and death recorded in this study, but mortality outcomes after stroke were associated with the intensity of weekend staffing by registered nurses. The accuracy of these findings may be affected by the measure used to judge the level of acute care available in each stroke unit and by residual confounding. For example, patients admitted to units with lower nursing levels may have shared other unknown characteristics that increased their risk of dying after stroke. Moreover, this study considered the impact of staffing levels on mortality only and did not consider other relevant outcomes such as long-term disability. Despite these limitations, these findings support the provision of higher weekend ratios of registered nurses to beds in stroke units, but given the high costs of increasing weekend staffing levels, it is important that controlled trials of different models of physician and nursing staffing are undertaken as soon as possible.
Additional Information
Please access these websites via the online version of this summary at http://dx.doi.org/10.1371/journal.pmed.1001705.
This study is further discussed in a PLOS Medicine Perspective by Meeta Kerlin
Information about plans to introduce seven-day working into the National Health Service in England is available; the 2013 publication “NHS Services—Open Seven Days a Week: Every Day Counts” provides examples of how hospitals across England are working together to provide routine healthcare services seven days a week; a “Behind the Headlines” article on the UK National Health Service Choices website describes a recent observational study that investigated the association between admission to hospital on the weekend and death, and newspaper coverage of the study's results; the Choices website also provides information about stroke for patients and their families, including personal stories
A US nurses' site includes information on the association of nurse staffing with patient safety
The US National Institute of Neurological Disorders and Stroke provides information about all aspects of stroke (in English and Spanish); its Know Stroke site provides educational materials about stroke prevention, treatment, and rehabilitation, including personal stories (in English and Spanish); the US National Institute of Health SeniorHealth website has additional information about stroke
The Internet Stroke Center provides detailed information about stroke for patients, families, and health professionals (in English and Spanish)
doi:10.1371/journal.pmed.1001705
PMCID: PMC4138029  PMID: 25137386
8.  Do personal stories make patient decision aids more effective? A critical review of theory and evidence 
Background
Patient decision aids support people to make informed decisions between healthcare options. Personal stories provide illustrative examples of others’ experiences and are seen as a useful way to communicate information about health and illness. Evidence indicates that providing information within personal stories affects the judgments and values people have, and the choices they make, differentially from facts presented in non-narrative prose. It is unclear if including narrative communications within patient decision aids enhances their effectiveness to support people to make informed decisions.
Methods
A survey of primary empirical research employing a systematic review method investigated the effect of patient decision aids with or without a personal story on people’s healthcare judgements and decisions. Searches were carried out between 2005-2012 of electronic databases (Medline, PsycINFO), and reference lists of identified articles, review articles, and key authors. A narrative analysis described and synthesised findings.
Results
Of 734 citations identified, 11 were included describing 13 studies. All studies found participants’ judgments and/or decisions differed depending on whether or not their decision aid included a patient story. Knowledge was equally facilitated when the decision aids with and without stories had similar information content. Story-enhanced aids may help people recall information over time and/or their motivation to engage with health information. Personal stories affected both “system 1” (e.g., less counterfactual reasoning, more emotional reactions and perceptions) and “system 2” (e.g., more perceived deliberative decision making, more stable evaluations over time) decision-making strategies. Findings exploring associations with narrative communications, decision quality measures, and different levels of literacy and numeracy were mixed. The pattern of findings was similar for both experimental and real-world studies.
Conclusions
There is insufficient evidence that adding personal stories to decision aids increases their effectiveness to support people’s informed decision making. More rigorous research is required to elicit evidence about the type of personal story that a) encourages people to make more reasoned decisions, b) discourages people from making choices based on another’s values, and c) motivates people equally to engage with healthcare resources.
doi:10.1186/1472-6947-13-S2-S9
PMCID: PMC4044102  PMID: 24625283
9.  What Explains Usage of Mobile Physician-Rating Apps? Results From a Web-Based Questionnaire 
Background
Consumers are increasingly accessing health-related information via mobile devices. Recently, several apps to rate and locate physicians have been released in the United States and Germany. However, knowledge about what kinds of variables explain usage of mobile physician-rating apps is still lacking.
Objective
This study analyzes factors influencing the adoption of and willingness to pay for mobile physician-rating apps. A structural equation model was developed based on the Technology Acceptance Model and the literature on health-related information searches and usage of mobile apps. Relationships in the model were analyzed for moderating effects of physician-rating website (PRW) usage.
Methods
A total of 1006 randomly selected German patients who had visited a general practitioner at least once in the 3 months before the beginning of the survey were randomly selected and surveyed. A total of 958 usable questionnaires were analyzed by partial least squares path modeling and moderator analyses.
Results
The suggested model yielded a high model fit. We found that perceived ease of use (PEOU) of the Internet to gain health-related information, the sociodemographic variables age and gender, and the psychographic variables digital literacy, feelings about the Internet and other Web-based applications in general, patients’ value of health-related knowledgeability, as well as the information-seeking behavior variables regarding the amount of daily private Internet use for health-related information, frequency of using apps for health-related information in the past, and attitude toward PRWs significantly affected the adoption of mobile physician-rating apps. The sociodemographic variable age, but not gender, and the psychographic variables feelings about the Internet and other Web-based applications in general and patients’ value of health-related knowledgeability, but not digital literacy, were significant predictors of willingness to pay. Frequency of using apps for health-related information in the past and attitude toward PRWs, but not the amount of daily Internet use for health-related information, were significant predictors of willingness to pay. The perceived usefulness of the Internet to gain health-related information and the amount of daily Internet use in general did not have any significant effect on both of the endogenous variables. The moderation analysis with the group comparisons for users and nonusers of PRWs revealed that the attitude toward PRWs had significantly more impact on the adoption and willingness to pay for mobile physician-rating apps in the nonuser group.
Conclusions
Important variables that contribute to the adoption of a mobile physician-rating app and the willingness to pay for it were identified. The results of this study are important for researchers because they can provide important insights about the variables that influence the acceptance of apps that allow for ratings of physicians. They are also useful for creators of mobile physician-rating apps because they can help tailor mobile physician-rating apps to the consumers’ characteristics and needs.
doi:10.2196/jmir.3122
PMCID: PMC4071227  PMID: 24918859
physician-rating apps; physician-rating websites; sociodemographic variables; psychographic variables; digital literacy; TAM
10.  Individual differences in competent consumer choice: the role of cognitive reflection and numeracy skills 
In this paper, we investigate whether cognitive reflection and numeracy skills affect the quality of the consumers’ decision-making process in a purchase decision context. In a first (field) experiment, an identical product was on sale in two shops with different initial prices and discounts. One of the two deals was better than the other and the consumers were asked to choose the best one and to describe which arithmetic operations they used to solve the problem; then they were asked to complete the numeracy scale (Lipkus et al., 2001). The choice procedures used by the consumers were classified as “complete decision approach” when all the arithmetic operations needed to solve the problem were computed, and as “partial decision approach” when only some operations were computed. A mediation model shows that higher numeracy is associated with use of the complete decision approach. In turn, this approach is positively associated with the quality of the purchase decision. Given that these findings highlight the importance of the decision processes, in a second (laboratory) experiment we used a supplementary method to study the type of information search used by the participants: eye-tracking. In this experiment the participants were presented with decision problems similar to those used in Experiment 1 and they completed the Lipkus numeracy scale and the Cognitive Reflection Test (CRT; Frederick, 2005). Participants with a high CRT score chose the best deal more frequently, and showed a more profound and detailed information search pattern compared to participants with a low CRT score. Overall, results indicate that higher levels of cognitive reflection and numeracy skills predict the use of a more thorough decision process (measured with two different techniques: retrospective verbal reports and eye movements). In both experiments the decision process is a crucial factor which greatly affects the quality of the purchase decision.
doi:10.3389/fpsyg.2015.00844
PMCID: PMC4469827  PMID: 26136721
numeracy; CRT; eye movements; decision-making processes; economic choice
11.  Impact of different food label formats on healthiness evaluation and food choice of consumers: a randomized-controlled study 
BMC Public Health  2009;9:184.
Background
Front of pack food labels or signpost labels are currently widely discussed as means to help consumers to make informed food choices. It is hoped that more informed food choices will result in an overall healthier diet. There is only limited evidence, as to which format of a food label is best understood by consumers, helps them best to differentiate between more or less healthy food and whether these changes in perceived healthiness result in changes of food choice.
Methods
In a randomised experimental study in Hamburg/Germany 420 adult subjects were exposed to one of five experimental conditions: (1) a simple "healthy choice" tick, (2) a multiple traffic light label, (3) a monochrome Guideline Daily Amount (GDA) label, (4) a coloured GDA label and (5) a "no label" condition. In the first task they had to identify the healthier food items in 28 pair-wise comparisons of foods from different food groups. In the second task they were asked to select food portions from a range of foods to compose a one-day's consumption. Differences between means were analysed using ANOVAs.
Results
Task I: Experimental conditions differed significantly in the number of correct decisions (p < 0.001). In the condition "no label" subjects had least correct decisions (20.2 ± 3.2), in the traffic light condition most correct decisions were made (24.8 ± 2.4). Task II: Envisaged daily food consumption did not differ significantly between the experimental conditions.
Conclusion
Different food label formats differ in the understanding of consumers. The current study shows, that German adults profit most from the multiple traffic light labels. Perceived healthiness of foods is influenced by this label format most often. Nevertheless, such changes in perceived healthiness are unlikely to influence food choice and consumption. Attempts to establish the informed consumer with the hope that informed choices will be healthier choices are unlikely to change consumer behaviour and will not result in the desired contribution to the prevention of obesity and diet related diseases.
doi:10.1186/1471-2458-9-184
PMCID: PMC2702386  PMID: 19523212
12.  The Influence of Distance and Level of Care on Delivery Place in Rural Zambia: A Study of Linked National Data in a Geographic Information System 
PLoS Medicine  2011;8(1):e1000394.
Using linked national data in a geographic information system system, Sabine Gabrysch and colleagues investigate the effects of distance to care and level of care on women's use of health facilities for delivery in rural Zambia.
Background
Maternal and perinatal mortality could be reduced if all women delivered in settings where skilled attendants could provide emergency obstetric care (EmOC) if complications arise. Research on determinants of skilled attendance at delivery has focussed on household and individual factors, neglecting the influence of the health service environment, in part due to a lack of suitable data. The aim of this study was to quantify the effects of distance to care and level of care on women's use of health facilities for delivery in rural Zambia, and to compare their population impact to that of other important determinants.
Methods and Findings
Using a geographic information system (GIS), we linked national household data from the Zambian Demographic and Health Survey 2007 with national facility data from the Zambian Health Facility Census 2005 and calculated straight-line distances. Health facilities were classified by whether they provided comprehensive EmOC (CEmOC), basic EmOC (BEmOC), or limited or substandard services. Multivariable multilevel logistic regression analyses were performed to investigate the influence of distance to care and level of care on place of delivery (facility or home) for 3,682 rural births, controlling for a wide range of confounders. Only a third of rural Zambian births occurred at a health facility, and half of all births were to mothers living more than 25 km from a facility of BEmOC standard or better. As distance to the closest health facility doubled, the odds of facility delivery decreased by 29% (95% CI, 14%–40%). Independently, each step increase in level of care led to 26% higher odds of facility delivery (95% CI, 7%–48%). The population impact of poor geographic access to EmOC was at least of similar magnitude as that of low maternal education, household poverty, or lack of female autonomy.
Conclusions
Lack of geographic access to emergency obstetric care is a key factor explaining why most rural deliveries in Zambia still occur at home without skilled care. Addressing geographic and quality barriers is crucial to increase service use and to lower maternal and perinatal mortality. Linking datasets using GIS has great potential for future research and can help overcome the neglect of health system factors in research and policy.
Please see later in the article for the Editors' Summary
Editors' Summary
Background
Approximately 360,000 women die each year in pregnancy and childbirth, of which more than 200,000 in sub-Saharan Africa, where a woman's lifetime risk of dying during or following pregnancy remains as high as 1 in 31 (compared to 1 in 4,300 in the developed world). The target of Millennium Development Goal 5 is to reduce the maternal mortality ratio by three quarters by 2015. Most maternal and neonatal deaths in low-income countries could be prevented if all women delivered their babies in settings where skilled birth attendants (such as midwives) were available and could provide emergency obstetric care to both mothers and babies in case of complications. Yet every year roughly 50 million women give birth at home without skilled care.
Why was this study done?
The likelihood of a woman giving birth in a health facility under the care of a skilled birth attendant depends on many factors. These include characteristics of the mother and her family, such as education level and household wealth, and aspects of the health service environment—distance to the nearest health facility and the quality of care provided at that facility, for example. However, research to date has typically focused on household and individual factors, neglecting the influence of the health service environment on choice of delivery place, largely because suitable data was not available. In this study in rural Zambia, the researchers aimed to quantify the effects of the health service environment, namely distance to health care and the level of care provided, on pregnant women's use of health facilities for giving birth. To put these factors in context, the researchers compared the impact of distance to quality care on place of delivery to that of other important factors, such as poverty and education.
What did the researchers do and find?
Using a geographic information system (GIS), the researchers linked national household data (from the 2007 Zambia Demographic and Health Survey) with national facility data (from the 2005 Zambian Health Facility Census) and calculated straight-line distances between women's villages and health facilities. Health facilities were classified as providing comprehensive emergency obstetric care, basic emergency obstetric care, or limited or substandard services by using reported capability to perform a certain number of the eight emergency obstetric care signal functions: injectable antibiotics, injectable oxytocics, injectable anticonvulsants, manual removal of placenta, manual removal of retained products, assisted vaginal delivery, cesarean section, and blood transfusion, as well as criteria on staffing, opening hours and referral capacity. The researchers used data from 3,682 rural births and multivariable multilevel logistic regression analyses to investigate whether distance to, and level of care at the closest delivery facility influence place of delivery (health facility or home), keeping other influential factors constant.
The researchers found that only a third of births in rural Zambia occurred at a health facility, and half of all mothers who gave birth lived more than 25 km from a health facility that provided basic emergency obstetric services. As distance to the closest health facility doubled, the odds of a women giving birth in a health facility decreased by 29%. Independently, each step increase in the level of emergency obstetric care provided at the closest delivery facility led to an increased likelihood (26% higher odds) of a woman delivering her baby at a facility. The researchers estimated that the impact of poor geographic access to emergency obstetric services was of similar magnitude as that of low maternal education, household poverty, or lack of female autonomy.
What do these findings mean?
The results of this study suggest that poor geographic access to emergency obstetric care is a key factor in explaining why most women in rural Zambia still deliver their babies at home without skilled care. Therefore, in order to increase the number of women delivering in health facilities and thus reduce maternal and neonatal mortality, it is crucial to address the geographic and quality barriers to delivery service use. Furthermore, the methodology used in this study—linking datasets using GIS— has great potential for future research as it can help explore the influence of health system factors also for other health problems.
Additional Information
Please access these websites via the online version of this summary at http://dx.doi.org/10.1371/journal.pmed.1000394.
Information about emergency obstetric care is provided by the United Nations Population Fund (UNFPA)
Various topics on maternal health are presented by WHO, WHO Regional Office Africa, by UNPFA, and UNICEF
WHO offers detailed information about MDG5
Family Care International offers more information about maternal and neonatal health
The Averting Maternal Death and Disability program (AMDD) provides information on needs assessments of emergency obstetric and newborn care
Countdown to 2015 tracks progress in maternal, newborn, and child survival
WHO provides free online viewing of BBC Fight for Life videos describing delivery experiences in different countries
doi:10.1371/journal.pmed.1000394
PMCID: PMC3026699  PMID: 21283606
13.  Addressing health literacy in patient decision aids 
Background
Effective use of a patient decision aid (PtDA) can be affected by the user’s health literacy and the PtDA’s characteristics. Systematic reviews of the relevant literature can guide PtDA developers to attend to the health literacy needs of patients. The reviews reported here aimed to assess:
1. a) the effects of health literacy / numeracy on selected decision-making outcomes, and b) the effects of interventions designed to mitigate the influence of lower health literacy on decision-making outcomes, and
2. the extent to which existing PtDAs a) account for health literacy, and b) are tested in lower health literacy populations.
Methods
We reviewed literature for evidence relevant to these two aims. When high-quality systematic reviews existed, we summarized their evidence. When reviews were unavailable, we conducted our own systematic reviews.
Results
Aim 1: In an existing systematic review of PtDA trials, lower health literacy was associated with lower patient health knowledge (14 of 16 eligible studies). Fourteen studies reported practical design strategies to improve knowledge for lower health literacy patients. In our own systematic review, no studies reported on values clarity per se, but in 2 lower health literacy was related to higher decisional uncertainty and regret. Lower health literacy was associated with less desire for involvement in 3 studies, less question-asking in 2, and less patient-centered communication in 4 studies; its effects on other measures of patient involvement were mixed. Only one study assessed the effects of a health literacy intervention on outcomes; it showed that using video to improve the salience of health states reduced decisional uncertainty. Aim 2: In our review of 97 trials, only 3 PtDAs overtly addressed the needs of lower health literacy users. In 90% of trials, user health literacy and readability of the PtDA were not reported. However, increases in knowledge and informed choice were reported in those studies in which health literacy needs were addressed.
Conclusion
Lower health literacy affects key decision-making outcomes, but few existing PtDAs have addressed the needs of lower health literacy users. The specific effects of PtDAs designed to mitigate the influence of low health literacy are unknown. More attention to the needs of patients with lower health literacy is indicated, to ensure that PtDAs are appropriate for lower as well as higher health literacy patients.
doi:10.1186/1472-6947-13-S2-S10
PMCID: PMC4042520  PMID: 24624970
14.  Uncovering patterns of technology use in consumer health informatics 
Internet usage and accessibility has grown at a staggering rate, influencing technology use for healthcare purposes. The amount of health information technology (Health IT) available through the Internet is immeasurable and growing daily. Health IT is now seen as a fundamental aspect of patient care as it stimulates patient engagement and encourages personal health management. It is increasingly important to understand consumer health IT patterns including who is using specific technologies, how technologies are accessed, factors associated with use, and perceived benefits. To fully uncover consumer patterns it is imperative to recognize common barriers and which groups they disproportionately affect. Finally, exploring future demand and predictions will expose significant opportunities for health IT. The most frequently used health information technologies by consumers are gathering information online, mobile health (mHealth) technologies, and personal health records (PHRs). Gathering health information online is the favored pathway for healthcare consumers as it is used by more consumers and more frequently than any other technology. In regard to mHealth technologies, minority Americans, compared with White Americans utilize social media, mobile Internet, and mobile applications more frequently. Consumers believe PHRs are the most beneficial health IT. PHR usage is increasing rapidly due to PHR integration with provider health systems and health insurance plans. Key issues that have to be explicitly addressed in health IT are privacy and security concerns, health literacy, unawareness, and usability. Privacy and security concerns are rated the number one reason for the slow rate of health IT adoption.
doi:10.1002/wics.1276
PMCID: PMC4041299  PMID: 24904713
informatics; personal health record; technology; consumer; patient; medical data
15.  Development and initial evaluation of a treatment decision dashboard 
Background
For many healthcare decisions, multiple alternatives are available with different combinations of advantages and disadvantages across several important dimensions. The complexity of current healthcare decisions thus presents a significant barrier to informed decision making, a key element of patient-centered care.
Interactive decision dashboards were developed to facilitate decision making in Management, a field marked by similarly complicated choices. These dashboards utilize data visualization techniques to reduce the cognitive effort needed to evaluate decision alternatives and a non-linear flow of information that enables users to review information in a self-directed fashion. Theoretically, both of these features should facilitate informed decision making by increasing user engagement with and understanding of the decision at hand. We sought to determine if the interactive decision dashboard format can be successfully adapted to create a clinically realistic prototype patient decision aid suitable for further evaluation and refinement.
Methods
We created a computerized, interactive clinical decision dashboard and performed a pilot test of its clinical feasibility and acceptability using a multi-method analysis. The dashboard summarized information about the effectiveness, risks of side effects and drug-drug interactions, out-of-pocket costs, and ease of use of nine analgesic treatment options for knee osteoarthritis. Outcome evaluations included observations of how study participants utilized the dashboard, questionnaires to assess usability, acceptability, and decisional conflict, and an open-ended qualitative analysis.
Results
The study sample consisted of 25 volunteers - 7 men and 18 women - with an average age of 51 years. The mean time spent interacting with the dashboard was 4.6 minutes. Mean evaluation scores on scales ranging from 1 (low) to 7 (high) were: mechanical ease of use 6.1, cognitive ease of use 6.2, emotional difficulty 2.7, decision-aiding effectiveness 5.9, clarification of values 6.5, reduction in decisional uncertainty 6.1, and provision of decision-related information 6.0. Qualitative findings were similarly positive.
Conclusions
Interactive decision dashboards can be adapted for clinical use and have the potential to foster informed decision making. Additional research is warranted to more rigorously test the effectiveness and efficiency of patient decision dashboards for supporting informed decision making and other aspects of patient-centered care, including shared decision making.
doi:10.1186/1472-6947-13-51
PMCID: PMC3639808  PMID: 23601912
16.  Toward Automated Consumer Question Answering: Automatically Separating Consumer Questions from Professional Questions in the Healthcare Domain 
Journal of biomedical informatics  2011;44(6):1032-1038.
Objective
Both healthcare professionals and healthcare consumers have information needs that can be met through the use of computers, specifically via medical question answering systems. However, the information needs of both groups are different in terms of literacy levels and technical expertise, and an effective question answering system must be able to account for these differences if it is to formulate the most relevant responses for users from each group. In this paper, we propose that a first step toward answering the queries of different users is automatically classifying questions according to whether they were asked by healthcare professionals or consumers.
Design
We obtained two sets of consumer questions (~10,000 questions in total) from Yahoo answers. The professional questions consist of two question collections: 4654 point-of-care questions (denoted as PointCare) obtained from interviews of a group of family doctors following patient visits and 5378 questions from physician practices through professional online services (denoted as OnlinePractice). With more than 20,000 questions combined, we developed supervised machine-learning models for automatic classification between consumer questions and professional questions. To evaluate the robustness of our models, we tested the model that was trained on the Consumer-PointCare dataset on the Consumer-OnlinePractice dataset. We evaluated both linguistic features and statistical features and examined how the characteristics in two different types of professional questions (PointCare vs. OnlinePractice) may affect the classification performance. We explored information gain for feature reduction and the back-off linguistic category features.
Results
10-fold cross-validation results showed the best F1-measure of 0.936 and 0.946 on Consumer-PointCare and Consumer-OnlinePractice respectively, and the best F1-measure of 0.891 when testing the Consumer-PointCare model on the Consumer-OnlinePractice dataset.
Conclusion
Healthcare consumer questions posted at Yahoo online communities can be reliably classified from professional questions posted by point-of-care clinicians and online physicians. The supervised machine-learning models are robust for this task. Our study will significantly benefit further development in automated consumer question answering.
doi:10.1016/j.jbi.2011.08.008
PMCID: PMC3226885  PMID: 21856442
question classification; medical question answering; supervised machine learning; support vector machines; natural language processing
17.  Internet Skills Performance Tests: Are People Ready for eHealth? 
Background
Despite the amount of online health information, there are several barriers that limit the Internet’s adoption as a source of health information. One of these barriers is highlighted in conceptualizations of the digital divide which include the differential possession of Internet skills, or “eHealth literacy”. Most measures of Internet skills among populations at large use self-assessments. The research discussed here applies a multifaceted definition of Internet skills and uses actual performance tests.
Objective
The purpose of this study was to assess how ready a sample of the general population is for eHealth. More specifically, four types of Internet skills were measured in a performance test in which subjects had to complete health-related assignments on the Internet.
Methods
From November 1, 2009, through February 28, 2010, 88 subjects participated in the study. Subjects were randomly selected from a telephone directory. A selective quota sample was used divided over equal subsamples of gender, age, and education. Each subject had to accomplish assignments on the Internet. The Internet skills accounted for were categorized as operational (basic skills to use the Internet), formal (navigation and orientation), information (finding information), and strategic (using the information for personal benefits). The tests took approximately 1.5 hours and were conducted in a University office, making the setting equally new for all. Successful completion and time spent on the assignments—the two main outcomes—were directly measured by the test leader.
Results
The subjects successfully completed an average of 73% (5.8/8) of the operational Internet skill tasks and an average of 73% (2.9/4) of the formal Internet skill tasks. Of the information Internet skills tasks, an average of 50% (1.5/3) was completed successfully and, of the strategic Internet skills tasks, 35% (0.7/2). Only 28% (25/88) of the subjects were able to successfully complete all operational skills tasks, 39% (34/88) all formal skills tasks, 13% (11/88) all information skills tasks, and 20% (18/88) both the strategic skill tasks. The time spent on the assignments varied substantially. Age and education were the most important contributors to the operational and formal Internet skills. Regarding the formal Internet skills, years of Internet experience also had some influence. Educational level of attainment was the most important contributor to the information and strategic Internet skills.
Conclusions
Although the amount of online health-related information and services is consistently growing, it appears that the general population lacks the skills to keep up. Most problematic appear to be the lack of information and strategic Internet skills, which, in the context of health, are very important. The lack of these skills is also problematic for members of younger generations, who are often considered skilled Internet users. This primarily seems to account for the operational and formal Internet skills. The results of the study strongly call for policies to increase the level of Internet skills.
doi:10.2196/jmir.1581
PMCID: PMC3221376  PMID: 21531690
Internet; eHealth; online; skills; literacy; information; digital divide
18.  Can High Quality Overcome Consumer Resistance to Restricted Provider Access? Evidence from a Health Plan Choice Experiment 
Health Services Research  2002;37(3):551-571.
Objective
To investigate the impact of quality information on the willingness of consumers to enroll in health plans that restrict provider access.
Data Sources and Setting
A survey administered to respondents between the ages of 25 and 64 in the West Los Angeles area with private health insurance.
Study Design
An experimental approach is used to measure the effect of variation in provider network features and information about the quality of network physicians on hypothetical plan choices. Conditional logit models are used to analyze the experimental choice data. Next, choice model parameter estimates are used to simulate the impact of changes in plan features on the market shares of competing health plans and to calculate the quality level required to make consumers indifferent to changes in provider access.
Principal Findings
The presence of quality information reduced the importance of provider network features in plan choices as hypothesized. However, there were not statistically meaningful differences by type of quality measure (i.e., consumer assessed versus expert assessed). The results imply that large quality differences are required to make consumers indifferent to changes in provider access. The impact of quality on plan choices depended more on the particular measure and less on the type of measure. Quality ratings based on the proportion of survey respondents “extremely satisfied with results of care” had the greatest impact on plan choice while the proportion of network doctors “affiliated with university medical centers” had the least. Other consumer and expert assessed measures had more comparable effects.
Conclusions
Overall the results provide empirical evidence that consumers are willing to trade high quality for restrictions on provider access. This willingness to trade implies that relatively small plans that place restrictions on provider access can successfully compete against less restrictive plans when they can demonstrate high quality. However, the results of this study suggest that in many cases, the level of quality required for consumers to accept access restrictions may be so high as to be unattainable. The results provide empirical support for the current focus of decision support efforts on consumer assessed quality measures. At the same time, however, the results suggest that consumers would also value quality measures based on expert assessments. This finding is relevant given the lack of comparative quality information based on expert judgment and research suggesting that consumers have apprehensions about their ability to meaningfully interpret performance-based quality measures.
doi:10.1111/1475-6773.00037
PMCID: PMC1434651  PMID: 12132595
Health plan choice; consumer; quality; quality information
19.  Women's Access and Provider Practices for the Case Management of Malaria during Pregnancy: A Systematic Review and Meta-Analysis 
PLoS Medicine  2014;11(8):e1001688.
Jenny Hill and colleagues conduct a systematic review and meta-analysis of women’s access and healthcare provider adherence to WHO case-management policy of malaria during pregnancy.
Please see later in the article for the Editors' Summary
Background
WHO recommends prompt diagnosis and quinine plus clindamycin for treatment of uncomplicated malaria in the first trimester and artemisinin-based combination therapies in subsequent trimesters. We undertook a systematic review of women's access to and healthcare provider adherence to WHO case management policy for malaria in pregnant women.
Methods and Findings
We searched the Malaria in Pregnancy Library, the Global Health Database, and the International Network for the Rational Use of Drugs Bibliography from 1 January 2006 to 3 April 2014, without language restriction. Data were appraised for quality and content. Frequencies of women's and healthcare providers' practices were explored using narrative synthesis and random effect meta-analysis. Barriers to women's access and providers' adherence to policy were explored by content analysis using NVivo. Determinants of women's access and providers' case management practices were extracted and compared across studies. We did not perform a meta-ethnography. Thirty-seven studies were included, conducted in Africa (30), Asia (4), Yemen (1), and Brazil (2). One- to three-quarters of women reported malaria episodes during pregnancy, of whom treatment was sought by >85%. Barriers to access among women included poor knowledge of drug safety, prohibitive costs, and self-treatment practices, used by 5%–40% of women. Determinants of women's treatment-seeking behaviour were education and previous experience of miscarriage and antenatal care. Healthcare provider reliance on clinical diagnosis and poor adherence to treatment policy, especially in first versus other trimesters (28%, 95% CI 14%–47%, versus 72%, 95% CI 39%–91%, p = 0.02), was consistently reported. Prescribing practices were driven by concerns over side effects and drug safety, patient preference, drug availability, and cost. Determinants of provider practices were access to training and facility type (public versus private). Findings were limited by the availability, quality, scope, and methodological inconsistencies of the included studies.
Conclusions
A systematic assessment of the extent of substandard case management practices of malaria in pregnancy is required, as well as quality improvement interventions that reach all providers administering antimalarial drugs in the community. Pregnant women need access to information on which anti-malarial drugs are safe to use at different stages of pregnancy.
Please see later in the article for the Editors' Summary
Editors' Summary
Background
Malaria, a mosquito-borne parasite, kills about 600,000 people every year. Most of these deaths occur among young children in sub-Saharan Africa, but pregnant women and their unborn babies are also vulnerable to malaria. Infection with malaria during pregnancy can cause severe maternal anemia, miscarriages, and preterm births, and kills about 10,000 women and 100,000 children each year. Since 2006, the World Health Organization (WHO) has recommended that uncomplicated malaria (an infection that causes a fever but does not involve organ damage or severe anemia) should be treated with quinine and clindamycin if it occurs during the first trimester (first three months) of pregnancy and with an artemisinin-based combination therapy (ACT) if it occurs during the second or third trimester; ACTs should be used during the first trimester only if no other treatment is immediately available because their safety during early pregnancy has not been established. Since 2010, WHO has also recommended that clinical diagnosis of malaria should be confirmed before treatment by looking for parasites in patients' blood (parasitology).
Why Was This Study Done?
Prompt diagnosis and treatment of malaria in pregnancy in regions where malaria is always present (endemic regions) is extremely important, yet little is known about women's access to the recommended interventions for malaria in pregnancy or about healthcare providers' adherence to the WHO case management guidelines. In this systematic review and meta-analysis of qualitative, quantitative, and mixed methods studies, the researchers explore the factors that affect women's access to treatment and healthcare provider practices for case management of malaria during pregnancy. A systematic review uses predefined criteria to identify all the research on a given topic. Meta-analysis is a statistical method for combining the results of several studies. A qualitative study collects non-quantitative data such as reasons for refusing an intervention, whereas a qualitative study collects numerical data such as the proportion of a population receiving an intervention.
What Did the Researchers Do and Find?
The researchers identified 37 studies (mostly conducted in Africa) that provided data on the range of healthcare providers visited, antimalarials used, and the factors influencing the choice of healthcare provider and medicines among pregnant women seeking treatment for malaria and/or the type and quality of diagnostic and case management services offered to them by healthcare providers. The researchers explored the data in these studies using narrative synthesis (which summarizes the results from several qualitative studies) and content analysis (which identifies key themes within texts). Among the studies that provided relevant data, one-quarter to three-quarters of women reported malaria episodes during pregnancy. More than 85% of the women who reported a malaria episode during pregnancy sought some form of treatment. Barriers to access to WHO-recommended treatment among women included poor knowledge about drug safety, and the use of self-treatment practices such as taking herbal remedies. Factors that affected the treatment-seeking behavior of pregnant women (“determinants”) included prior use of antenatal care, education, and previous experience of a miscarriage. Among healthcare providers, reliance on clinical diagnosis of malaria was consistently reported, as was poor adherence to the treatment policy. Specifically, 28% and 72% of healthcare providers followed the treatment guidelines for malaria during the first and second/third trimesters of pregnancy, respectively. Finally, the researchers report that concerns over side effects and drug safety, patient preference, drug availability, and cost drove the prescribing practices of the healthcare providers, and that the determinants of provider practices included the type (cadre) of heathcare worker, access to training, and whether they were based in a public or private facility.
What Do These Findings Mean?
These findings reveal important limitations in the implementation of the WHO policy on the treatment of malaria in pregnancy across many parts of Africa and in several other malaria endemic regions. Notably, they show that women do not uniformly seek care within the formal healthcare system and suggest that, when they do seek care, they may not be given the appropriate treatment because healthcare providers frequently fail to adhere to the WHO diagnostic and treatment guidelines. Although limited by the sparseness of data and by inconsistencies in study methodologies, these findings nevertheless highlight the need for further systematic assessments of the extent of substandard case management of malaria in pregnancy in malaria endemic countries, and the need to develop interventions to improve access to and delivery of quality case management of malaria among pregnant women.
Additional Information
Please access these websites via the online version of this summary at http://dx.doi.org/10.1371/journal.pmed.1001688.
Information is available from the World Health Organization on malaria (in several languages) and on malaria in pregnancy; the 2010 Guidelines for the Treatment of Malaria are available; the World Malaria Report 2013 provides details of the current global malaria situation
The US Centers for Disease Control and Prevention also provides information on malaria; a personal story about malaria in pregnancy is available
Information is available from the Roll Back Malaria Partnership on all aspects of global malaria control, including information on malaria in pregnancy
The Malaria in Pregnancy Consortium is undertaking research into the prevention and treatment of malaria in pregnancy and provides links to the consortium's publications and an online library on malaria in pregnancy
MedlinePlus provides links to additional information on malaria (in English and Spanish)
doi:10.1371/journal.pmed.1001688
PMCID: PMC4122360  PMID: 25093720
20.  The Impact of Health and Financial Literacy on Decision Making in Community-Based Older Adults 
Gerontology  2012;58(6):531-539.
Background
Health and financial literacy have been linked to the health and well-being of older adults, yet there are few data on how health and financial literacy actually impact decision making regarding healthcare and economic choices in advanced age.
Objective
To examine the association of health and financial literacy with decision making in older adults.
Method
Data came from 525 community-dwelling older persons without dementia from the Rush Memory and Aging Project, an ongoing longitudinal study of aging. Health and financial literacy were assessed via a series of questions designed to measure comprehension of health and financial information and concepts. The two scores were averaged to yield a total literacy score. A modified, 12-item version of the Decision-Making Competence Assessment Tool was used to measure financial and healthcare decision making (6 items each), using materials designed to approximate those used in real world settings. All 12 items were summed to yield a total decision-making score. Associations were tested via linear regression models adjusted for age, sex and education. Secondary models adjusted for global cognitive function, income, depression and chronic medical conditions.
Results
On average, participants correctly answered 67% of the literacy questions (health literacy = 61.6%, SD = 18.8% and financial literacy = 72.5%, SD = 16.0%). After adjustment for cognitive function, the total literacy score was positively associated with the decision-making total score (estimate = 0.64, SE = 0.08, p < 0.001), as well as healthcare (estimate = 0.37, SE = 0.5, p < 0.001) and financial decision making (estimate = 0.28, SE = 0.05, p < 0.001). Further, total literacy, health and financial literacy all were independently associated with decision making in models adjusted for covariates including income, depression, and chronic medical conditions (all p values < 0.001). Finally, there was evidence of effect modification such that the beneficial association between literacy and healthcare decision making was stronger among older persons, poorer persons and persons at the lower ranges of cognitive ability.
Conclusion
Among community based older persons without dementia, higher levels of health and financial literacy were associated with better decision making, suggesting that improvements in literacy could facilitate better decision making and lead to better health and quality of life in later years.
doi:10.1159/000339094
PMCID: PMC3491105  PMID: 22739454
Financial literacy; Health literacy; Decision making
21.  Low Health Literacy and Evaluation of Online Health Information: A Systematic Review of the Literature 
Background
Recent years have witnessed a dramatic increase in consumer online health information seeking. The quality of online health information, however, remains questionable. The issue of information evaluation has become a hot topic, leading to the development of guidelines and checklists to design high-quality online health information. However, little attention has been devoted to how consumers, in particular people with low health literacy, evaluate online health information.
Objective
The main aim of this study was to review existing evidence on the association between low health literacy and (1) people’s ability to evaluate online health information, (2) perceived quality of online health information, (3) trust in online health information, and (4) use of evaluation criteria for online health information.
Methods
Five academic databases (MEDLINE, PsycINFO, Web of Science, CINAHL, and Communication and Mass-media Complete) were systematically searched. We included peer-reviewed publications investigating differences in the evaluation of online information between people with different health literacy levels.
Results
After abstract and full-text screening, 38 articles were included in the review. Only four studies investigated the specific role of low health literacy in the evaluation of online health information. The other studies examined the association between educational level or other skills-based proxies for health literacy, such as general literacy, and outcomes. Results indicate that low health literacy (and related skills) are negatively related to the ability to evaluate online health information and trust in online health information. Evidence on the association with perceived quality of online health information and use of evaluation criteria is inconclusive.
Conclusions
The findings indicate that low health literacy (and related skills) play a role in the evaluation of online health information. This topic is therefore worth more scholarly attention. Based on the results of this review, future research in this field should (1) specifically focus on health literacy, (2) devote more attention to the identification of the different criteria people use to evaluate online health information, (3) develop shared definitions and measures for the most commonly used outcomes in the field of evaluation of online health information, and (4) assess the relationship between the different evaluative dimensions and the role played by health literacy in shaping their interplay.
doi:10.2196/jmir.4018
PMCID: PMC4468598  PMID: 25953147
health information seeking; online health information; information quality; health literacy
22.  The Effect of Alternative Summary Statistics for Communicating Risk Reduction on Decisions about Taking Statins: A Randomized Trial 
PLoS Medicine  2009;6(8):e1000134.
Carling and colleagues carry out a trial evaluating different methods of communicating information to people regarding the risks and benefits of taking statins. They suggest that natural frequencies are likely to be the most appropriate summary statistic for presenting the effects of treatment.
Background
While different ways of presenting treatment effects can affect health care decisions, little is known about which presentations best help people make decisions consistent with their own values. We compared six summary statistics for communicating coronary heart disease (CHD) risk reduction with statins: relative risk reduction and five absolute summary measures—absolute risk reduction, number needed to treat, event rates, tablets needed to take, and natural frequencies.
Methods and Findings
We conducted a randomized trial to determine which presentation resulted in choices most consistent with participants' values. We recruited adult volunteers who participated through an interactive Web site. Participants rated the relative importance of outcomes using visual analogue scales (VAS). We then randomized participants to one of the six summary statistics and asked them to choose whether to take statins based on this information. We calculated a relative importance score (RIS) by subtracting the VAS scores for the downsides of taking statins from the VAS score for CHD. We used logistic regression to determine the association between participants' RIS and their choice. 2,978 participants completed the study. Relative risk reduction resulted in a 21% higher probability of choosing to take statins over all values of RIS compared to the absolute summary statistics. This corresponds to a number needed to treat (NNT) of 5; i.e., for every five participants shown the relative risk reduction one additional participant chose to take statins, compared to the other summary statistics. There were no significant differences among the absolute summary statistics in the association between RIS and participants' decisions whether to take statins. Natural frequencies were best understood (86% reported they understood them well or very well), and participants were most satisfied with this information.
Conclusions
Presenting the benefits of taking statins as a relative risk reduction increases the likelihood of people accepting treatment compared to presenting absolute summary statistics, independent of the relative importance they attach to the consequences. Natural frequencies may be the most suitable summary statistic for presenting treatment effects, based on self-reported preference, understanding of and satisfaction with the information, and confidence in the decision.
Clinical Trials Registration
ISRCTN85194921
Please see later in the article for the Editors' Summary
Editors' Summary
Background
People often have to make decisions about their health care. Ideally, all the health care decisions that a person makes should be those best suited to his or her personal circumstances and expectations. Take, for example, someone with a high amount of cholesterol (a type of fat) in his or her blood. Because this condition increases the chances of developing potentially fatal coronary heart disease (CHD), such a person will often be advised by his or her doctor to take statins to reduce blood cholesterol levels. However, the person needs to consider both the benefits and downsides of this course of action. Can he or she afford to pay for statins, if their health care system requires him or her to? Does the person want to take a pill every day that might cause some side effects? That is, the person has to consider his or her “values”—the relative desirability of all the possible outcomes of taking statins—before deciding whether to follow his or her doctor's advice.
Why Was This Study Done?
It is well known that how information is presented to patients about treatment options and their consequences affects the choices that they make. For example, patients who are told that a drug will halve their chances of developing a disease (a 50% relative risk reduction) are more likely to decide to take that drug than those who are told it will reduce their absolute (actual) risk of developing the disease from 4% to 2%. Less is known, however, about which presentations of treatment effects best help people to make decisions that are consistent with their own values. In 2002, therefore, a series of internet-based randomized trials (studies in which participants are randomly allocated to different “treatment” groups) called the Health Information Project: Presentation Online (HIPPO) was initiated. Here, the researchers describe HIPPO 2, a trial that investigates how alternative summary statistics for communicating the reduction of CHD risk with statins affect people's decisions to take statins.
What Did the Researchers Do and Find?
Nearly 3,000 adults in Norway and North America rated the relative importance to them of CHD risk reduction, the cost of statins, and the need to take a daily pill through an interactive Web site. The researchers used these data to calculate a “relative importance score” (RIS), an indicator of each participant's values. Each participant then decided whether or not to take statins after being shown one of six summary statistics about the effect of statins on CHD risk (relative risk reduction and five indicators of absolute risk reduction). The presentation of the effect of statins as a relative risk reduction resulted in more people deciding to take statins over the whole RIS range than any of the absolute summary statistics. For every five participants shown the relative risk reduction statistic, an extra participant chose to take statins compared to the other summary statistics. When asked to compare the six summary statistics, the statistic that most people preferred and understood best was the “natural frequency,” an absolute summary statistic that gave the number of people likely to develop CHD with and without statin treatment.
What Do These Findings Mean?
Although these findings may not be generalizable to other populations or to other medical decisions, they provide new insights into how the presentation of information can affect the choices people make about health care. Specifically, these findings indicate that the presentation of the reduced risk of getting CHD as a result of taking stains as a relative amount is more likely to persuade people to take statins than several absolute summary statistics. They also suggest that the persuasive effect of the relative risk reduction summary statistic is not affected by the relative importance attached to the consequences of taking statins by individuals. That is, people shown the relative risk reduction statistic may be more likely to start statins to reduce their CHD risk (or a drug that reduces the risk of developing another disease) whatever their personal values than people shown absolute summary statistics. Finally, the findings on participant preferences suggest that natural frequencies may be the best summary statistic to include in tools designed to help people make decisions about their healthcare.
Additional Information
Please access these Web sites via the online version of this summary at http://dx.doi.org/10.1371/journal.pmed.1000134.
A PLoS Medicine Editorial discusses this trial and the results of another HIPPO trial that are presented in a separate PLoS Medicine Research Article by Carling and colleagues; details of a pilot HIPPO trial are also available
The Foundation for Informed Medical Decision Making (a US-based non-profit organization) provides information on many aspects of medical decision making
The Dartmouth-Hitchcock Medical Center provides information to help people make health care decisions through its Center for Shared Decision Making
The Ottawa Hospital Research Institute provides also information on patient decision aids, including an inventory of decision aids available on the Web (in English and French)
MedlinePlus provides links to information and advice about statins and about coronary heart disease (in English and Spanish)
doi:10.1371/journal.pmed.1000134
PMCID: PMC2724738  PMID: 19707575
23.  Patient satisfaction in an acute medicine department in Morocco 
Background
Patients' satisfaction is an important indicator for quality of care. Measuring healthcare quality and improving patient satisfaction have become increasingly prevalent, especially among healthcare providers and purchasers of healthcare. This is mainly due to the fact that consumers are becoming increasingly more knowledgeable about healthcare. No studies of inpatients' satisfaction with hospital care have been conducted in Morocco. The first objective of the present study was to confirm the reliability and validity of the Arabic version of the EQS-H (Echelle de Qualité des Soins en Hospitalisation). The second objective was to evaluate patient satisfaction in an acute medicine department in Morocco by using the EQS-H questionnaire; and also to assess the influence of certain demographics, socioeconomics, and health characteristics in patient satisfaction.
Methods
it was a patient survey conducted in an acute medicine department of a Moroccan University Hospital. We surveyed their socio demographic status, and health characteristics at admission. We performed structured face to face interviews with patients who were discharged from hospital. The core of the EQS-H questionnaire was translated to Arabic, adapted to the present setting, and then used to measure patient satisfaction with quality of care. The internal consistency of the EQS-H scale was assessed by Chronbach's coefficient alpha. Validity was assessed by factor analysis. Factors influencing inpatients' satisfaction were identified using multiple linear regression.
Results
The Arabic version of EQS-H demonstrated an excellent internal consistency for the two dimensions studied (0.889 for 'quality of medical information' (MI) and 0.906 for 'Relationship with staff and daily routine' (RS)). The principal component analysis confirmed the bidimensional structure of the questionnaire and explained 60% of the total variance. In the univariate analysis, urban residence, higher income, better perceived health status compared to admission, better perceived health status compared to people of the same age, and satisfaction with life in general were related to MI dimension; Otherwise, mal gender, urban residence, higher income, staying in double room, better perceived health status compared to admission, and satisfaction with life in general were related to RS dimension. The multiple linear regression showed that four independent variables were associated with higher satisfaction in MI: More than 2 prior hospitalizations, a longer length of stay (10-14 days) (P = 0.002), staying in double room (P = 0.022), and better perceived health status compared to admission (P = 0.036). Three independent variables were associated with higher satisfaction in RS: a longer length of stay (10-14 days) (P = 0.017), better perceived health status compared to admission day (P = 0.013), and satisfaction with life in general (P = 0.006).
Conclusions
Our current data assessing patient satisfaction with acute health care by the Arabic version of the EQS-H showed that the satisfaction rate was average on MI dimension; and good on RS dimension of the questionnaire. The majority of participants were satisfied with the overall care. Demographic, socioeconomic, and health characteristics may influence in-patients satisfaction in Morocco, a low/middle income country. An appreciation and understanding of these factors is essential to develop socio culturally appropriate interventions in order to improve satisfaction of patients.
doi:10.1186/1472-6963-10-149
PMCID: PMC2900260  PMID: 20525170
24.  Physician Awareness of Drug Cost: A Systematic Review 
PLoS Medicine  2007;4(9):e283.
Background
Pharmaceutical costs are the fastest-growing health-care expense in most developed countries. Higher drug costs have been shown to negatively impact patient outcomes. Studies suggest that doctors have a poor understanding of pharmaceutical costs, but the data are variable and there is no consistent pattern in awareness. We designed this systematic review to investigate doctors' knowledge of the relative and absolute costs of medications and to determine the factors that influence awareness.
Methods and Findings
Our search strategy included The Cochrane Library, EconoLit, EMBASE, and MEDLINE as well as reference lists and contact with authors who had published two or more articles on the topic or who had published within 10 y of the commencement of our review. Studies were included if: either doctors, trainees (interns or residents), or medical students were surveyed; there were more than ten survey respondents; cost of pharmaceuticals was estimated; results were expressed quantitatively; there was a clear description of how authors defined “accurate estimates”; and there was a description of how the true cost was determined. Two authors reviewed each article for eligibility and extracted data independently. Cost accuracy outcomes were summarized, but data were not combined in meta-analysis because of extensive heterogeneity. Qualitative data related to physicians and drug costs were also extracted. The final analysis included 24 articles. Cost accuracy was low; 31% of estimates were within 20% or 25% of the true cost, and fewer than 50% were accurate by any definition of cost accuracy. Methodological weaknesses were common, and studies of low methodological quality showed better cost awareness. The most important factor influencing the pattern and accuracy of estimation was the true cost of therapy. High-cost drugs were estimated more accurately than inexpensive ones (74% versus 31%, Chi-square p < 0.001). Doctors consistently overestimated the cost of inexpensive products and underestimated the cost of expensive ones (binomial test, 89/101, p < 0.001). When asked, doctors indicated that they want cost information and feel it would improve their prescribing but that it is not accessible.
Conclusions
Doctors' ignorance of costs, combined with their tendency to underestimate the price of expensive drugs and overestimate the price of inexpensive ones, demonstrate a lack of appreciation of the large difference in cost between inexpensive and expensive drugs. This discrepancy in turn could have profound implications for overall drug expenditures. Much more focus is required in the education of physicians about costs and the access to cost information. Future research should focus on the accessibility and reliability of medical cost information and whether the provision of this information is used by doctors and makes a difference to physician prescribing. Additionally, future work should strive for higher methodological standards to avoid the biases we found in the current literature, including attention to the method of assessing accuracy that allows larger absolute estimation ranges for expensive drugs.
From a review of data from 24 studies, Michael Allan and colleagues conclude that doctors often underestimate the price of expensive drugs and overestimate the price of those that are inexpensive.
Editors' Summary
Background.
Many medicines are extremely expensive, and the cost of buying them is a major (and increasing) proportion of the total cost of health care. Governments and health-care organizations try to find ways of keeping down costs without reducing the effectiveness of the health care they provide, but their efforts to control what is spent on medicines have not been very successful. There are often two or more equally effective drugs available for treating the same condition, and it would obviously help keep costs down if, when a doctor prescribes a medicine, he or she chose the cheapest of the effective drugs available. This choice could result in savings for whoever is paying for the drugs, be it the government, the patient, or a medical insurance organization.
Why Was This Study Done?
Doctors who prescribe drugs cannot be expected to know the exact cost of each drug on the market, but it would he helpful if they had some impression of the cost of a treatment and how the various alternatives compare in price. However, systems deciding how drugs are priced are often very complex. (This is particularly the case in the US.) The researchers wanted to find out how aware doctors are regarding drug costs and the difference between the alternatives. They also wanted to know what factors affected their awareness.
What Did the Researchers Do and Find?
They decided to do a systematic review of all the research already conducted that addressed this issue so that the evidence from all of them could be considered together. In order to do such a review they had to specify precise requirements for the type of study that they would include and then comprehensively search the medical literature for such studies. They found 24 studies that met their requirements. From these studies, they concluded that doctors were usually not accurate when asked to estimate the cost of drugs; doctors came up with estimates that were within 25% of the true cost less than one-third of the time. In particular doctors tended to underestimate the cost of expensive drugs and overestimate the cost of the cheaper alternatives. A further analysis of the studies showed that many doctors said they would appreciate more accurate information on costs to help them choose which drugs to prescribe but that such information was not readily available.
What Do These Findings Mean?
The researchers concluded that their systematic review demonstrates a lack of appreciation by prescribing doctors of the large difference in cost between inexpensive and expensive drugs, and that this finding has serious implications for overall spending on drugs. They call for more education and information to be provided to doctors on the cost of medicines together with better processes to help doctors in making such decisions.
Additional Information.
Please access these Web sites via the online version of this summary at http://dx.doi.org/10.1371/journal.pmed.0040283.
A brief guide to systematic reviews has been published by the BMJ (British Medical Journal)
The Web site of the Cochrane Collaboration is a more detailed source of information on systematic reviews; in particular there is a newcomers' guide and information for health-care consumers
The Kaiser Family Foundation, a nonprofit, private operating foundation focusing on the major health care issues in the US, has a section on prescription drugs and their costs
doi:10.1371/journal.pmed.0040283
PMCID: PMC1989748  PMID: 17896856
25.  The development of health literacy in patients with a long-term health condition: the health literacy pathway model 
BMC Public Health  2012;12:130.
Background
Inadequate health literacy has been associated with poor management of long-term health conditions and has been identified as a key social determinant of health outcomes. However, little is understood about how health literacy might develop over time or the processes by which people may become more health literate. Our objectives were to describe how patients with a long-term condition practice health literacy in the management of their health and communication with health professionals, how they become more health literate over time and their experience of using health services. We also sought to identify and describe the motivations, facilitators and barriers in the practice of health literacy in healthcare consultations.
Methods
We designed a longitudinal qualitative study using serial interviews with 18 participants to explore their experiences of learning to manage their condition and their experiences of health literacy when participating in healthcare processes. Participants were recruited from patient education programmes and were interviewed three times over a period of 9 months. A framework approach was used to analyse data.
Results
A model is presented that illustrates the development of health literacy along a trajectory that includes the development of knowledge, health literacy skills and practices, health literacy actions, abilities in seeking options and informed and shared decision making opportunities. Motivations and barriers to developing and practising health literacy skills partly reflected participants' characteristics but were also influenced by health professionals. Some participants developed their health literacy to a point where they became more involved in healthcare processes (including informed and shared decision-making).
Conclusions
Patients with a long-term condition can develop health literacy skills over time and put their skills into practice in becoming more active in healthcare consultations. Our findings have implications for developing health literacy interventions aimed at patient involvement in healthcare processes and improved self-management of long-term conditions.
doi:10.1186/1471-2458-12-130
PMCID: PMC3305618  PMID: 22332990

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