A trusting relationship between patients, physicians, and the healthcare system is important in encouraging self-care behaviors in cardiovascular patients. The study aimed to assess the prevalence of healthcare system and physician distrust in this population, compare the two forms of distrust, and describe the demographic, socioeconomic, and psycho-social predictors of high distrust. 1232 hospitalized adults with acute coronary syndrome or heart failure were enrolled in a prospective, observational study assessing both healthcare system and physician distrust. High healthcare system distrust (35%) was observed across the population, with lower levels of interpersonal physician distrust (16%). In a multivariate analysis, poor social support and coping skills were strong predictors of both healthcare system (p = 0.026, p = 0.003) and physician distrust (p <0.001, p = 0.006). Individuals with low or marginal health literacy had a higher likelihood of physician distrust (p <0.001), but no relationship was found between health literacy and healthcare system distrust. In conclusion, distrust is common among acutely ill cardiac patients. Those with low social support and low coping skills are more distrusting of physicians and the healthcare system.
trust; healthcare system; health literacy; cardiovascular disease
Little research has examined the association of health literacy and numeracy with patients' preferred involvement in the problem-solving and decision-making process in the hospital. Using a sample of 1,249 patients hospitalized with cardiovascular disease from the Vanderbilt Inpatient Cohort Study (VICS), we assessed patients' preferred level of involvement using responses to two scenarios of differing symptom severity from the Problem-Solving Decision-Making (PSDM) Scale. Using multivariable modeling, we determined the relationship of health literacy, subjective numeracy, and other patient characteristics with preferences for involvement in decisions, and how this differed by scenario. We found that patients with higher levels of health literacy desired more participation in the problem-solving and decision-making process, as did patients with higher subjective numeracy skills, greater educational attainment, female gender, less perceived social support, or greater health care system distrust (p<0.05 for each predictor in multivariable models). Patients also preferred to participate more in the decision-making process when the hypothetical symptom they were experiencing was less severe (i.e., they deferred more to their physician when the hypothetical symptom was more severe). These findings underscore the role that patient characteristics, especially health literacy and numeracy, play in decisional preferences among hospitalized patients.
Health literacy; Decision Making; Decisional preferences; Problem Solving; Numeracy
Breast cancer is the most common cause of cancer and the leading cause of cancer death among Latinas in the United States. In addition, Latinas experience a disproportionate burden of cervical cancer incidence, morbidity, and mortality compared with non-Hispanic White women. Lower use of breast and cervical cancer screening services may contribute to these disparities. To address the underutilization of breast and cervical cancer screening among diverse subgroups of Latinas, a peer-led education program called Esperanza y Vida (“Hope and Life”) was developed and administered at 3 sites (2 in New York and 1 in Arkansas). Immigrant Latina women and their partners were educated about the importance of breast and cervical cancer screening, with the goals of increasing their knowledge about these cancers and their screening behavior. An analysis of the intervention’s findings at baseline among female participants demonstrated significant sociodemographic, interpersonal, cultural, health care system, and program variability in 3 distinct geographic regions in the United States. These data indicate the need for and feasibility of customizing cancer outreach and educational programs for diverse Latina subgroups living in various U.S. regions, with implications for informing the expansion and replication of the program in other regions of the country.
Health literacy is related to a broad range of health outcomes. This study was designed to develop a psychometrically sound instrument designed to measure cancer health literacy along a continuum (CHLT-30), to develop another instrument designed to determine whether a patient has limited cancer health literacy (CHLT-6), and to estimate the prevalence of limited cancer health literacy. The Cancer Health Literacy Study involving 1,306 Black and White cancer patients was conducted between April 2011 and April 2013 in the Virginia Commonwealth University Massey Cancer Center and surrounding oncology clinics. A continuous latent variable modeling framework was adopted to dimensionally represent cancer health literacy, whereas discrete latent variable modeling was used to estimate the prevalence rates of limited cancer health literacy. Self confidence about engaging in health decisions was used as the primary outcome in external validation of new instruments. Results from a comprehensive analysis strongly supported the construct validity and reliability of the CHLT-30 and CHLT-6. For both instruments, measurement invariance tests ruled out item/test bias to explain gender and race/ethnicity differences in test scores. The limited cancer health literacy rate was 18%, a subpopulation consisting of overrepresented Black, undereducated, and low-income cancer patients. Overall, the results supported the conclusion that the CHLT-30 accurately measures cancer health literacy along a continuum and that the CHLT-6 efficiently identifies patients with limited cancer health literacy with high accuracy.
Few family-based interventions to increase sun safe behavior among adolescents have been evaluated. The present study tested an intervention that included tailored and nontailored print communications delivered by mail to adolescents (age 11 to 15) and their parents who were also participating in an evaluation of an in-school intervention. The use of sunscreen, protective clothing, and avoidance of the sun were promoted, and family communication and environmental change strategies were fostered. Adolescents and their parents were pretested in May of 2002 and posttested from August to October. Adolescents (N=599) were stratified on experimental condition in the in-school study (in-school intervention vs control) and randomly were assigned from within strata to receive (N=288) or not receive (N=311) the summer intervention materials. No statistically significant effects were found for adolescents between the randomized experimental conditions. Parents’ had increased knowledge (F = 5.52, p <. 05) and propensity to have their child wear sunglasses (F = 4.07, p <. 05). Greater program exposure/engagement led to enhanced sun protection behavior (e.g., fewer sunburns) and psychosocial factors among adolescents and parents. Greater exposure/engagement led to improvements in family interaction and home environment (e.g., shade audit completed). Future research is needed on exposure/engagement with family-based health messaging and on family-based sun safety programs for adolescents.
Limited health literacy is recognized as contributing to racial/ethnic and other health disparities through mechanisms of poor understanding and adherence, and limited access to health care. Recent studies have focused on interventions to address literacy gaps between patients and healthcare providers, focusing on communication techniques and redefining the responsibility for closing gaps. Cultural differences between patient and provider, if left unaddressed, have been shown to contribute to poor health outcomes through misunderstanding, value conflicts and disparate concepts of health and illness. The dual challenges of limited health literacy and cultural differences are likely to increase with an expanding, increasingly diverse and older population. There is evidence that training providers to attend to both issues can reduce medical errors, improve adherence, patient-provider-family communication and outcomes of care at both individual and population levels. The two fields continue to have separate trajectories, vocabularies and research agendas, competing for limited curricular resources. We present a conceptual framework for health professions education that attends simultaneously to limited health literacy and cultural differences as a coherent way forward in training culturally competent providers with a common skill-set to deliver patient-centered care that focuses on health disparities reduction.
The amount of cancer-related information available to the general population continues to grow, yet its effects are unclear. This study extends previous cross-sectional research establishing that cancer information seeking across a variety of sources is extensive and positively associated with engaging in health-related behaviors. We studied how active information seeking about cancer prevention influenced three healthy lifestyle behaviors using a two-round nationally representative sample of adults ages 40–70 (n=1795), using propensity scoring to control for potential confounders including baseline behavior. The adjusted odds of dieting at follow-up were 1.51 [95% CI: 1.05 to 2.19] times higher for those who reported baseline seeking from media and interpersonal sources relative to non-seekers. Baseline seekers ate 0.59 [95% CI: 0.28, 0.91] more fruits/vegetable servings per day and exercised 0.36 [95% CI: 0.12 to 0.60] more days per week at one-year follow-up compared to non-seekers. The effects of seeking from media and friends/family on eating fruits/vegetables and exercising were independent of seeking from physicians. We offer several explanations for why information seeking predicts healthy lifestyle behaviors: information obtained motivates these behaviors; information sought teaches specific techniques; the act of information seeking may reinforce a psychological commitment to dieting, eating fruits/vegetables, and exercising.
Of the alcohol-related risks faced by college students, it is arguable that none presents a greater public health hazard than driving after drinking (DAD). The present study examined the extent to which students’ injunctive misperceptions toward DAD predicted the likelihood to engage in DAD and how this relation was mediated by self-approval of DAD. Participants were 2,848 college students (59.1% female, 64.6% Caucasian) from two U.S. West Coast universities who completed confidential web-based surveys assessing DAD beliefs and behaviors. Results revealed that respondents tended to overestimate their peers’ approval toward DAD. Moreover, the subgroups likely to engage in DAD—men, 21+ years of age, Greek affiliated students, Caucasians, students with a family history of alcohol abuse—were also more likely to misperceive (i.e., overestimate) their peers’ level of approval toward DAD. Using binary logistic regression analyses, self-approval of DAD emerged as an important statistical mediator in the relation between misperception of typical student approval toward DAD and engagement in DAD. Results point to the considerable role injunctive peer misperceptions may play in the pathways leading to drinking-driving risk. These findings provide preliminary support for DAD-specific social normative interventions, either complementing or supplementing existing alcohol interventions. By targeting high-risk student subgroups and communicating accurate drinking-driving norms, these proposed interventions have the potential to reduce self-approval and incidence of DAD.
Three large randomized trials are described from the Cancer Information Service Research Consortium (CISRC). Three web-based multimedia programs are being tested to help newly diagnosed prostate (Project 1) and breast cancer patients (Project 2) make informed treatment decisions and breast cancer patients prepare for life after treatment (Project 3). Project 3 is also testing a telephone callback intervention delivered by a cancer information specialist. All participants receive standard print material specific to each project. Preliminary results from the two-month follow-up interviews are reported for the initial wave of enrolled participants, most of whom were recruited from the Cancer Information Service (1-800-4-CANCER) telephone information program (Project 1 = 208, Project 2 = 340, Project 3 = 792). Self-reported use of the multimedia program was 51%, 52% and 67% for Projects 1–3, respectively. Self-reported use of the print materials (read all, most or some) was 90%, 85% and 83% for Projects 1–3, respectively. The callback intervention was completed by 92% of Project 3 participants. Among those using the CISRC interventions, perceived utility and benefit was high, and more than 90% would recommend them to other cancer patients. Five initial lessons learned are presented that may help inform future cancer communications research.
Research on health information exposure focuses primarily on deliberate information seeking behavior and its effects on health. By contrast, this study explores the complementary and perhaps more influential role of health information acquired through exposure to routinely used sources, called scanning. We hypothesized that scanning from non-medical sources, both mediated and interpersonal, affects cancer screening and prevention decisions. A nationally representative longitudinal survey of adults 40 to 70 years (N=2,489) was used to analyze the effects of scanning on three cancer screening behaviors (mammography, PSA, colonoscopy) and three prevention behaviors (exercising, eating fruits and vegetables, dieting to lose weight). After adjustment for baseline behaviors and covariates, scanning at baseline predicted one year later weekly exercise days overall, as well as daily fruits and vegetables servings for those already higher on baseline consumption. Also among those reporting timely screening mammogram behavior at baseline, scanning predicted repeat mammography. Scanning was marginally predictive of PSA uptake among those not reporting a PSA at baseline. While there were strong cross-sectional associations, scanning did not predict dieting or colonoscopy uptake in longitudinal analyses. These analyses provide substantial support for a claim that routine exposure to health content from non-medical sources affects specific health behaviors.
Despite the importance of family environment and computer-mediated social support (CMSS) for women with breast cancer, little is known about the interplay of these sources of care and assistance on patients' coping strategies. To understand this relation, the authors examined the effect of family environment as a predictor of the use of CMSS groups as well as a moderator of the relation between group participation and forms of coping. Data were collected from 111 patients in CMSS groups in the Comprehensive Health Enhancement Support System “Living with Breast Cancer” intervention. Results indicate that family environment plays a crucial role in (a) predicting breast cancer patient's participation in CMSS groups and (b) moderating the effects of use of CMSS groups on breast cancer patients' coping strategies such as problem-focused coping and emotion-focused coping.
This study evaluated a tailored intervention to promote sun protection in parents and their children, hypothesizing that the tailored intervention would lead to improved skin cancer prevention behaviors compared to generic materials. Families were recruited through schools and community centers and were included if there was one child in Grades 1–3 at moderate to high risk for skin cancer. Participants were randomized into one of two intervention groups: a tailored intervention, in which they received personalized skin cancer education through the mail; or a control group who received generic skin cancer information materials. Both pre- and post-intervention, parents completed questionnaires about their and their children’s skin cancer risk and prevention knowledge and behaviors. Parents also completed 4-day sun exposure and protection diaries for their child and themselves. Tailored group participants demonstrated significantly greater positive changes in prevention behavior after the intervention, including children’s use of sunscreen, shirts, and hats, and parents’ use of shade, and skin examinations. Effect sizes were small and perceived benefits and social norms mediated intervention effects. Findings from this study support the efficacy of focusing tailored communications to families in order to change skin cancer prevention practices in young children.
Aversion to “ambiguity”—uncertainty about the reliability, credibility, or adequacy of risk-related information—is an important problem that may influence judgments and decisions about medical interventions. Ambiguity aversion (AA) varies among individuals, however, and has been understudied in the health domain. To explore this phenomenon further, we developed a new theory-based measure of aversion to ambiguity regarding medical tests and treatments, and examined the prevalence and association of AA with sociodemographic factors. The “AA-Med” scale was developed using a large survey sample of the U.S. public (n = 4,398), and scale psychometric properties and the population distribution of AA were evaluated. The scale demonstrated acceptable reliability (α = .73) and validity as ascertained by association with respondents’ interest in a hypothetical ambiguous cancer screening test. Ambiguity aversion (AA) was associated with older age, non-White race, lower education and income, and female sex. The AA-Med scale is a promising new measure, and AA is associated with several sociodemographic factors. We discuss implications of these findings and potential applications of the scale for future research.
Health numeracy can be defined as the ability to understand and use numeric information and quantitative concepts in the context of health. We previously reported the development of the Numeracy Understanding in Medicine Instrument (NUMi); a 20-item test developed using item response theory. We now report the development and validation of a short form of the NUMi.
Item statistics were used to identify a subset of 8-items representing a range of difficulty and content areas. Internal reliability was evaluated with Cronbach's alpha. Divergent and convergent validity was assessed by comparing scores of the S-NUMI with existing measures of education, print and numeric health literacy, mathematic achievement, cognitive reasoning, and the original NUMi.
The 8-item scale had adequate reliability (Cronbach's alpha: 0.72) and was strongly correlated to the 20-item NUMi (0.92). The S-NUMi scores were strongly correlated with the Lipkus numeracy test (0.62), Wide Range of Achievement Test-Mathematics (WRAT-M) (0.72), and Wonderlic cognitive reasoning test (0.76). Moderate correlation was found with education level (0.58) and print literacy as measured by the TOFHLA (0.49).
The short Numeracy Understanding in Medicine Instrument is a reliable and valid measure of health numeracy feasible for use in clinical and research settings.
Obese women are at higher risk for several cancers, but are less likely than normal weight women to engage in cancer prevention behaviors such as screening and physical activity. Targeted health messages may help increase healthy behaviors among vulnerable groups such as obese women. Using findings from focus groups with obese women, the authors created targeted messages to promote colorectal cancer screening and physical activity among obese women. The messages addressed psychosocial constructs, such as benefits and barriers to colorectal cancer screening and exercise, which were relevant to the target population. Messages were tested online with women age 50 years and older (N = 181). Participants were stratified by weight (obese vs. nonobese) and randomized to review either 10 targeted (intervention) or 10 generic (control) messages. Study outcomes included elaboration about the messages, message relevance and trustworthiness, and behavioral intentions. The authors used moderation and subgroup analyses to determine whether the intervention messages were better received by certain women. They found no differences in elaboration, behavioral intentions, relevance, or trustworthiness between intervention and control for either weight group. However, exercise intentions increased more (p=.06) among inactive obese women who received intervention messages (+2.9) compared with those who were in the control group (+1.2). Intervention messages also produced more elaboration among women who viewed their weight as a barrier to screening or exercise. Tailoring intervention messages for obese women on the basis of behavior and barriers may improve outcomes more than giving the same messages to all obese women.
In this study, we apply the concept of “ambiguity,” as developed in the decision theory literature, to an analysis of potential psychological consequences of uncertainty about cancer prevention recommendations. We used Health Information National Trends Survey (HINTS) 2003 data to examine how perceived ambiguity about cancer prevention recommendations relates to three other cognitive variables known to influence cancer-protective behavior: perceived cancer preventability, perceived cancer risk, and cancer-related worry. Using logistic regression analyses, we tested several predictions derived from a review of literature on the effects of ambiguity perceptions on decision making, cognitions, and emotions. We found perceived ambiguity to have a strong negative relationship with perceived cancer preventability, consistent with “ambiguity aversion”—a pessimistic bias in the interpretation of ambiguity. Cancer worry moderated this relationship; ambiguity aversion increased with higher levels of worry. At the same time, perceived ambiguity was positively related to both perceived cancer risk and cancer worry. Furthermore, perceived risk partially mediated the relationship between perceived ambiguity and worry. These findings suggest that perceived ambiguity about cancer prevention recommendations may have broad and important effects on other health cognitions. We discuss ethical implications of these findings for health communication efforts, and propose a tentative causal model to guide future research.
Identity-based strategies have been suggested as a way to promote healthy behaviors when traditional approaches fall short. The truth® campaign, designed to reduce smoking in adolescents, is an example of a campaign that uses such a strategy to reach youth described as being outside the mainstream. This article examines the effectiveness of this strategy in promoting antitobacco company beliefs among youth. Survey data from 224 adolescents between 14 and 15 years of age were used to examine whether the truth® campaign was more or less effective at reaching and promoting antitobacco company beliefs among youth who identify with nonmainstream crowds (deviants and counterculture) versus those who identify with mainstream crowds (elites and academics). Analyses revealed that adolescents who identified as deviants and counterculture were more likely to have been persuaded by the truth® campaign. Social identity theory is used as a theoretical framework to understand these effects and to make recommendations for future health campaigns.
This article reports on a combined family-based substance abuse and HIV prevention intervention targeting families with children ages 13-14 in Bangkok, Thailand. Families (n=340) were randomly and proportionally selected from seven districts in Bangkok with half randomly assigned to an experimental or control condition. Families in the intervention condition were exposed to five interactive booklets about adolescent substance use and risky sexual behavior. Trained health educators followed up by phone to encourage completion of each booklet. Primary outcomes reported in this paper include whether the intervention increased the frequency of parent/child communication in general or about sexual risk taking in particular as well as whether the intervention reduced discomfort discussing sexual issues. We also tested to see if booklet completion was associated with communication outcomes at the 6-month follow-up. Multivariate findings indicate that the intervention significantly affected the frequency of general parent/child communication based on child reports. The intervention marginally affected frequency of parent/child communication about sexual issues based on parent reports. Booklet completion was associated with reduced discomfort discussing sex and was marginally associated with frequency of parent/child discussion of sex based on parent reports only. These findings indicate that a family-based program can have an impact on communication patterns.
Concern over health risks is the most common motivation for quitting smoking. Health warnings on tobacco packages are among the most prominent interventions to convey the health risks of smoking. Face-to-face surveys were conducted in Mexico (n=1,072), and a web-based survey was conducted in the US (n=1,449) to examine the efficacy of health warning labels on health beliefs. Respondents were randomly assigned to view two sets of health warnings (each with one text-only warning and 5–6 pictorial warnings) for two different health effects. Respondents were asked whether they believed smoking caused 12 different health effects. Overall, the findings indicate high levels of health knowledge in both countries for some health effects, although significant knowledge gaps remained; for example: less than half of respondents agreed that smoking causes impotence and less than one third agreed that smoking causes gangrene. Mexican respondents endorsed a greater number of correct beliefs about the health impact of smoking than the US sample. In both countries, viewing related health warning labels increased beliefs about the health risks of smoking, particularly for less well-known health effects, such as gangrene, impotence, and stroke.
To develop a conceptual framework for the construct of health numeracy based on patient perceptions.
Interested participants (n=59) meeting eligibility criteria (age 40–74, English speaking) were assigned to one of 6 focus groups stratified by gender and educational level (low, medium, high). 53% were male and 47% were female. 61% were white non-Hispanic and 39% were of minority race or ethnicity.
Participants were randomly selected from 3 primary care sites associated with an academic medical center. The focus groups were held in May, 2004.
Group discussions focused on how numbers are used in the health care setting. Data were presented from clinical trials to further explore how quantitative information is used in health communication and decision-making. Focus groups were audio and videotaped; verbatim transcripts were prepared and analyzed. A framework of health numeracy was developed to reflect the themes that emerged.
Three broad conceptual domains for health numeracy were identified: primary numeric skills, applied health numeracy, and interpretive health numeracy. Across domains, results suggested that numeracy contains an emotional component; with both positive and negative affect reflected in patient numeracy statements.
Health numeracy is a multifaceted construct that includes applied and interpretive components and is influenced by patient affect.
Communication; decision making; communication skills; health literacy; health numeracy
As the United States becomes more linguistically and culturally diverse, there is a need for effective health communication interventions that target diverse and most vulnerable populations. Latinos also have the lowest colorectal (CRC) screening rates of any ethnic group in the U.S. To address such disparities, health communication interventionists are often faced with the challenge to adapt existing interventions from English into Spanish in a way that retains essential elements of the original intervention while also addressing the linguistic needs and cultural perspectives of the target population. We describe the conceptual framework, context, rationale, methods, and findings of a formative research process used in creating a Spanish language version of an evidenced-based (English language) multimedia CRC screening decision aid. Our multi-step process included identification of essential elements of the existing intervention, literature review, assessment of the regional context and engagement of key stakeholders, and solicitation of direct input from target population. We integrated these findings in the creation of the new adapted intervention. We describe how we used this process to identify and integrate socio-cultural themes such as personalism (personalismo), familism (familismo), fear (miedo), embarrassment (verguenza), power distance (respeto), machismo, and trust (confianza) into the Spanish language decision aid.
Decision aid; Adaptation; Latinos; Limited English proficiency; Colorectal cancer screening
Health communication and health information technology influence the ways in which health care professionals and the public seek, use, and comprehend health information. The Health Information National Trends Survey (HINTS) program was developed to assess the effect of health communication and health information technology on health-related attitudes, knowledge, and behavior. HINTS has fielded 3 national data collections with the fourth (HINTS 4) currently underway. Throughout this time, the Journal of Health Communication has been a dedicated partner in disseminating research based on HINTS data. Thus, the authors thought it the perfect venue to provide an historical overview of the HINTS program and to introduce the most recent HINTS data collection effort. This commentary describes the rationale for and structure of HINTS 4, summarizes the methodological approach applied in Cycle 1 of HINTS 4, describes the timeline for the HINTS 4 data collection, and identifies priorities for research using HINTS 4 data.
Successful anti-marijuana messages can be hypothesized to have two types of effects, namely persuasion effects, that is, a change in people’s beliefs about using marijuana, and priming effects, that is, a strengthened correlation between beliefs and associated variables such as attitude and intention. This study examined different sets of anti-drug advertisements for persuasion and priming effects. The ads targeted the belief that marijuana is a gateway to stronger drugs, a belief that is often endorsed by campaign planning officials and health educators. A sample of 418 middle and high school students was randomly assigned to a control video or one of three series of ads, two of which included the gateway message in either an explicit or implicit way. Results did not support the use of the gateway belief in anti-marijuana interventions. Whereas no clear persuasion or priming effects were found for any of the ad sequences, there is some possibility that an explicit gateway argument may actually boomerang. In comparison to the control condition, adolescents in the explicit gateway condition tended to agree less with the gateway message and displayed weaker correlations between anti-marijuana beliefs and their attitude toward marijuana use. The results suggest that the gateway message should not be used in anti-drug interventions.
Social media, specifically online weight loss message board communities, may become an important conduit for information about genetics and body weight. This information has the capacity to influence individuals as it is naturally encountered online, or could be strategically disseminated for public health purposes. However, little is known about how the public engages with information they encounter related to genetic underpinnings of body weight, or how their interpretation of this information shapes health beliefs. The current study examined discussions about genetics and weight in message board communities devoted to discussion of weight loss. Fifty-four online discussions, comprised of 505 individual posts from three weight loss-themed message boards were coded using a closed-ended procedure. Individuals who discussed genetics and weight in online message board communities initiated these discussions mainly for personal reasons and primarily cited mass media-sourced information. Genetic causes of weight tended to be endorsed alongside behavioral causes. There was no association between cause endorsements and expressed frustration. These findings help elucidate the effects of naturally-encountered information about genetics of weight. They may also have implications for the creation of online evidence-based tools to aid communication about genetic advances in ways that encourage positive dietary and physical activity behavior.