A Refined Teach-back Observation Tool: Validity Evidence in a Pediatric Setting.

BACKGROUND: Teach Back (TB) is recommended to assess and ensure patient understanding, thereby promoting safety, quality, and equity. There are many TB trainings, typically lacking assessment tools with validity evidence. We used a pediatric resident competency-based communication curriculum to develop initial validity evidence and refinement recommendations for a Teach-back Observation Tool (T-BOT). OBJECTIVE: This study aimed to develop initial validity evidence for a refined T-BOT and provide guidance for further enhancements to improve essential TB skills training among pediatric residents. METHODS: After an interactive health literacy (HL) training, residents participated in recorded standardized patient (SP) encounters. Raters developed T-BOT scoring criteria, then scored a gold standard TB video and resident SP encounters. For agreement, Fleiss' Kappa was computed for >2 raters, and Cohen's Kappa for two raters. Percent agreement and intraclass correlation (ICC) were calculated. Statistics were calculated for gold standard (GS) and TB items overall for all six raters, and for five faculty raters. Agreement was based on Kappa: no agreement (≤0), none to slight (0.01-0.20), fair (0.21-0.40), moderate (0.41-0.60), substantial (0.61-0.80), almost perfect (0.81-1.00). KEY RESULTS: For six raters, Kappa for the GS was 0.554 (moderate agreement) with 71.4% agreement; ICC = .597; for SP encounters, it was 0.637 (substantial) with 65.4% agreement; ICC = .647. Individual item agreement for SP encounters average was 0.605 (moderate), ranging from 0.142 (slight) to 1 (perfect). For five faculty raters, Kappa for the GS was 0.779 (substantial) with 85.7% agreement; ICC = .824; for resident SP encounters, it was 0.751 (substantial), with 76.9% agreement; ICC = .759. Individual item agreement on SP encounters average was 0.718 (substantial), ranging from 0.156 (slight) to 1 (perfect). CONCLUSION: We provide initial validity evidence for a modified T-BOT and recommendations for improvement. With further refinements to increase validity evidence, accompanied by shared understanding of TB and rating criteria, the T-BOT may be useful in strengthening approaches to teaching and improving essential TB skills among health care team members, thereby increasing organizational HL and improving outcomes. [HLRP: Health Literacy Research and Practice. 2023;7(4):e187-e196.].

PLAIN LANGUAGE SUMMARY: We provide initial validity evidence for a refined T-BOT and recommendations for further enhancements to improve essential TB skills among pediatric residents. With attention to a shared understanding of TB and rating criteria, this tool may be used to improve HL training, thereby increasing organizational HL and improving outcomes.

Building Community Health Literacy to Achieve Health Equity: Insights from Ethiopian Tewahedo Social Services Community Leader in a County-Level Health Literacy Initiative.

This perspectives article shares insights from a county-level project in Franklin County, Ohio, to build collective organizational health literacy (HL) capacity across new sustainable networks to advance community-level HL. We provide an overview of the initiative followed by specific insights from a cultural liaison, the article's first author, who works in a community-based organization. He shares his collectivist perspective in building HL capacity at the grassroots level toward community-level goals. A shift in focus from individual responsibility to collective impact represents an important mindset change for attaining HL and builds on community strengths and values toward health equity.

Closing knowledge gaps among parents of children with sickle cell trait.

BACKGROUND: Despite needing to be informed about sickle cell trait (SCT) status to make informed reproductive decisions, more than 80% of adults with SCT, including parents of children with SCT who have a high prevalence of SCT, do not know their status. PROCEDURE: This was a prospective study of parents who received SCT telephone education from the state department of health and then completed SCTaware, a videoconference-administered SCT education program. The objectives were to evaluate knowledge after telephone education and explore if SCTaware closes knowledge gaps. Participants completed a demographic survey, a health literacy assessment, and reported their SCT status. They completed the Sickle Cell Trait Knowledge Assessment before receiving SCTaware, immediately after, and at follow-up visits; high knowledge was a score of 75% or higher correct. RESULTS: SCTaware and the initial surveys were completed by 61 parents; 45 completed the 6-month surveys. Only 43% of participants had high SCT knowledge after telephone education; 92% achieved high knowledge immediately after, and 84% continued with high knowledge at 6 months. Most parents reported they were aware of their SCT status after telephone education; 12 changed their response after receiving SCTaware. CONCLUSIONS: Our findings suggest that over half of parents have low SCT knowledge following telephone education, and many may be unaware of their status. SCTaware closes knowledge gaps, leads to high sustained knowledge, and is a potentially scalable tool. Future studies should refine SCTaware and determine if parents use their knowledge to inform their children and reproductive decisions.

Acceptability to and Engagement With a Virtual Sickle Cell Trait Education Program (SCTaware): Single-Center Prospective Study.

BACKGROUND: Public health programs are tasked with educating the community on health topics, but it is unclear whether these programs are acceptable to learners. Currently, these programs are delivered via a variety of platforms including in-person, virtually, and over the telephone. Sickle cell trait (SCT) education for parents of children with this trait is one of many education programs provided by the Ohio Department of Health. The novel SCTaware videoconference education program was developed by a research team after central Ohio's standard program transitioned from in-person to telephone-only education during the COVID-19 pandemic. OBJECTIVE: Our objectives were to investigate the acceptability of the format and engagement with the SCTaware education and assess parental worry about having a child with SCT before and after receiving SCTaware. METHODS: This was a single-center, prospective study of English-speaking parents of children <3 years of age identified to have hemoglobin S trait by newborn screening. Parents who previously received SCT education by telephone, were able to be contacted, and had access to an electronic device capable of videoconferencing were eligible to complete surveys after receiving the virtual SCTaware education program. The SCTaware educator also completed a survey to assess participant engagement. Data were summarized descriptively and a McNemar test was used to compare parental worry before and after receiving SCTaware. RESULTS: In total, 55 participants completed follow-up surveys after receiving standard SCT telephone education and then completing SCTaware. Most (n=51) participants reported that the SCTaware content and visuals were very easy to understand (n=47) and facilitated conversation with the educator (n=42). All of them said the visuals were respectful and trustworthy, helped them understand content better, and that their questions were addressed. Nearly two-thirds (62%, n=34) reported that the pictures appeared very personal and applied to them. The educator noted most participants (n=45) were engaged and asked questions despite having to manage distractions during their education sessions. Many participants (n=33) reported some level of worry following telephone-only education; this was significantly reduced after receiving SCTaware (P<.001). CONCLUSIONS: Our results suggest that SCTaware is acceptable and engaging to parents. While telephone education may make SCT education more accessible, these findings suggest that many parents experience significant worry about their child with SCT after these sessions. A study to evaluate SCTaware's effectiveness at closing parents' SCT knowledge gaps is ongoing.

A Health Literate Approach to Address Health Disparities: a Virtual Program for Parents of Children with Sickle Cell Trait.

Background: Approximately 8% of African Americans born annually have sickle cell trait (SCT), a public health concern that may contribute to health disparities if individuals with SCT do not know it and lack access to understandable information about reproductive implications. Pre-pandemic, Ohio offered in-person SCT education for parents of SCT-affected children but many did not attend. Those with limited health literacy (HL) were less likely to achieve high knowledge. We used a HL-focused evaluation of this education to develop a virtual program (SCTaware) to communicate clear, actionable information and promote knowledge retention. Methods: Seven English-speaking parents, three with limited HL, were recruited in 2019 for in-person session videotaping and SCT knowledge assessments. Clinicians, HL experts, educators, genetic counselors, and parent stakeholders (evaluators) reviewed sessions, assessments, and accompanying visuals. Results: Evaluators: observed parents asked few questions; noted undefined technical terms, closed questions, key concept omission, and limited explanation of visuals scoring low for understandability, actionability, and clarity; and developed SCTaware for individual videoconference delivery (knowledge objectives; plain language guide; HL-informed communication strategies; new visuals scoring highly for understandability, actionability, and clarity; narrated post-education version; standardized educator training). Conclusions: Using a HL-focused evaluation, our diverse team created a promising virtual SCT education program addressing a common issue affecting populations at risk for disparities. Given virtual education will likely continue post-pandemic and limited HL is common, this approach may be essential and replicable for other public health education programs, especially those transitioning to virtual formats, to convey clear, actionable information and promote health equity.

Feasibility and usability study of a pilot immersive virtual reality-based empathy training for dental providers.

PURPOSE: Social determinants of health (SDOH) significantly impact individuals' engagement with the healthcare system. To address SDOH-related oral health disparities, providers must be equipped with knowledge, skills, and attitudes (KSAs) to understand how SDOH affect patients and how to mitigate these effects. Traditional dental school curricula provide limited training on recognizing SDOH or developing empathy for those with SDOH-related access barriers. This study describes the design and evaluation of such a virtual reality (VR)-based simulation in dental training. We hypothesize the simulation will increase post-training KSAs. METHODS: We developed "MPATHI" (Making Professionals Able THrough Immersion), a scripted VR simulation where participants take the role of an English-speaking caregiver with limited socioeconomic resources seeking dental care for a child in a Spanish-speaking country. The simulation is a combination of 360° video recording and virtual scenes delivered via VR headsets. A pilot was conducted with 29 dental residents/faculty, utilizing a pre-post design to evaluate effectiveness in improving immediate and retention of KSAs toward care delivery for families facing barriers. RESULTS: MPATHI led to increased mean scores for cognitive (pre = 3.48 ± 0.80, post = 4.56 ± 0.51, p < 0.001), affective (pre = 4.20 ± 0.4, post = 4.47 ± 0.44, p < 0.001), and skill-based learning (pre = 4.00 ± 0.47, post = 4.52 ± 0.37, p < 0.001) immediately post-training. There was not a significant difference between skills measured immediately post-training and in the 1-month post-training survey (p = 0.41). Participants reported high satisfaction with the content and methods used in this training. CONCLUSIONS: This pilot study supports using VR SDOH training in dental education. VR technology provides new opportunities for innovative content design.

Do health literacy disparities explain racial disparities in family-centered care for youths with special health care needs?

OBJECTIVE: To explore the relationship among youth health literacy, parental health literacy, and family-centered care (FCC) for youth with special health care needs (YSHCN) and assess potential racial disparities. METHODS: HL and FCC were assessed in 486 Medicaid-enrolled YSHCN (ages 12-18) and their healthcare-responsible parent/caregiver. Analyses assessed racial differences in HL and FCC for parents and youth using logistic regression. RESULTS: Half of youth and over 80 percent of parents had adequate HL (REALM score ≥62). Adequate HL was significantly lower in African Americans (AA) for both YSHCN and parents. Only 57 % of parents and 29 % of YSHCN reported FCC. AA YSHCN reported significantly lower levels of FCC compared to White YSHCN. AA parents trended lower for FCC compared to Whites, though the disparity was not significant. AA youth and parents had significantly lower odds of reporting that doctors spent enough time with them compared to Whites. CONCLUSION: Results suggest that AA and those with less than adequate health literacy experience lower FCC, however the relationship between race and health literacy does not explain the racial disparity in FCC. PRACTICAL IMPLICATIONS: Provider time spent focused on HL may not reduce the racial disparity in FCC, but opportunities for improvement exist.

Relationship between Teach-back and patient-centered communication in primary care pediatric encounters.

OBJECTIVE: We proposed and tested a theoretical framework for how use of Teach-back could influence communication during the pediatric clinical encounter. METHODS: Audio-taped pediatric primary care encounters with 44 children with asthma were coded using the Roter Interaction Analysis System to measure patient-centered communication and affective engagement of the parent. A newly created Teach-back Loop Score measured the extent to which Teach-back occurred during the clinical encounter; parental health literacy was measured by Newest Vital Sign. Logistic regression was used to test the relationship between Teach-back and features of communication. Focus groups held separately with clinicians and parents elicited perceptions of Teach-back usefulness. RESULTS: Teach-back was used in 39% of encounters. Visits with Teach-back had more patient centered communication (p=0.01). Adjusting for parent health literacy, parent age, and child age, Teach-back increased the odds of both patient centered communication [proportional AOR (95% CI)=4.97 (4.47-5.53)]and negative affect [AOR (95% CI)=5.39 (1.68-17.31)]. Focus group themes common to clinicians and parents included: Teach-back is effective, could cause discomfort, should be used with children, and nurses should use it. CONCLUSIONS: Teach-back was associated with more patient-centered communication and increased affective engagement of parents. PRACTICE IMPLICATIONS: Standardizing Teach-back use may strengthen patient-centered communication.

Improving patient-provider communication for patients having surgery: patient perceptions of a revised health literacy-based consent process.

OBJECTIVES: This research sought to describe and compare perceptions of consent-related health communication between surgical patients undergoing procedures at facilities that did and did not adopt a new health literacy-based consent form and process. METHODS: A self-administered, mail survey was used to collect information about demographic characteristics, health locus of control, and perceptions of surgical consent-related health communication from patients aged 18 years or older, approximately 2 to 4 months after undergoing laparascopic cholecystectomy, total hip replacement, or total knee replacement surgery within a 10-hospital integrated health system in Iowa. A static group comparison design with multivariable logistic regression analyses was used to compare perceptions about 12 aspects of surgical consent-related health communication between the adopting and nonadopting facilities while controlling for observed differences in respondent background characteristics using a threshold of P < 0.05 for model inclusion. RESULTS: Respondents from facilities implementing the new consent form and process had significantly higher odds of strongly agreeing that the nurses asked them to restate the type of surgery being performed in their own words (adjusted odds ratio, 1.92; 95% confidence interval, 1.30-2.82) and they were comfortable asking questions about their surgery (adjusted odds ratio, 1.53; 95% confidence interval, 1.04-2.26). CONCLUSIONS: The consent process can be refined to stimulate communication and comfort with asking questions, and promote use of health literacy-based techniques (i.e., teach-back) in the perioperative care setting. Adopting a health literacy-based informed consent process promotes patient safety and supports health providers' obligations to communicate in simple, clear, and plain language.

The health literacy of parents in the United States: a nationally representative study.

OBJECTIVE: To assess the health literacy of US parents and explore the role of health literacy in mediating child health disparities. METHODS: A cross-sectional study was performed for a nationally representative sample of US parents from the 2003 National Assessment of Adult Literacy. Parent performance on 13 child health-related tasks was assessed by simple weighted analyses. Logistic regression analyses were performed to describe factors associated with low parent health literacy and to explore the relationship between health literacy and self-reported child health insurance status, difficulty understanding over-the-counter medication labeling, and use of food labels. RESULTS: More than 6100 parents made up the sample (representing 72600098 US parents); 28.7% of the parents had below-basic/basic health literacy, 68.4% were unable to enter names and birth dates correctly on a health insurance form, 65.9% were unable to calculate the annual cost of a health insurance policy on the basis of family size, and 46.4% were unable to perform at least 1 of 2 medication-related tasks. Parents with below-basic health literacy were more likely to have a child without health insurance in their household (adjusted odds ratio: 2.4 [95% confidence interval: 1.1-4.9]) compared with parents with proficient health literacy. Parents with below-basic health literacy had 3.4 times the odds (95% confidence interval: 1.6-7.4) of reporting difficulty understanding over-the-counter medication labels. Parent health literacy was associated with nutrition label use in unadjusted analyses but did not retain significance in multivariate analyses. Health literacy accounted for some of the effect of education, racial/ethnic, immigrant-status, linguistic, and income-related disparities. CONCLUSIONS: A large proportion of US parents have limited health-literacy skills. Decreasing literacy demands on parents, including simplification of health insurance and other medical forms, as well as medication and food labels, is needed to decrease health care access barriers for children and allow for informed parent decision-making. Addressing low parent health literacy may ameliorate existing child health disparities.

Pediatricians and health literacy: descriptive results from a national survey.

OBJECTIVE: To describe pediatricians' self-reported experiences with health literacy, use of basic and enhanced communication techniques, and perceived barriers to effective communication during office visits. DESIGN/METHODS: A national, random sample of 1605 nonretired, posttraining American Academy of Pediatrics members were surveyed in 2007 about health literacy and patient communication as part of the Periodic Survey of Fellows. The response rate was 56% (N = 900). RESULTS: Eight-one percent of the pediatricians were aware of a situation in the previous 12 months in which a parent had not sufficiently understood health information that had been delivered to him or her. In addition, 44% of all pediatricians were aware of a communication-related error in patient care within the previous 12 months. Using simple language (99%), repeating key information (92%), and presenting only 2 or 3 concepts at a time (76%) were the most commonly used communication strategies. Enhanced communication techniques recommended by health literacy experts such as teach-back and indicating key points on written educational materials were used less often (23% and 28%, respectively). The most common reported barriers to effective communication were limited time to discuss information (73%), volume of information (65%), and complexity of information (64%). The majority of physicians rated themselves highly in their ability to identify caregiver understanding (64%), but only 21% rated themselves as very good or excellent in identifying a parent with a literacy problem. Fifty-seven percent of the respondents were interested in training to improve communication skills, and 58% reported that they would be very likely to use easy-to-read written materials, if available from the American Academy of Pediatrics. CONCLUSIONS: Pediatricians are aware of health literacy-related problems and the need for good communication with families but struggle with time demands to implement these skills. Despite awareness of communication-related errors in patient care, pediatricians report underutilizing enhanced techniques known to improve communication.

Literacy and child health: a systematic review.

OBJECTIVES: To assess the prevalence of low health literacy among adolescents, young adults, and child caregivers in the United States, the readability of common child-health information, and the relationship between literacy and child health. DATA SOURCES: MedLine, Educational Resources Information Center, National Library of Medicine, PsychInfo, Harvard Health Literacy Bibliography, and peer-reviewed abstracts from the Pediatric Academic Societies Annual Meetings. STUDY SELECTION: A systematic review using the following key words: health literacy, literacy, reading skill, numeracy, and Wide Range Achievement Test. MAIN OUTCOME MEASURES: Descriptive studies that used at least 1 valid measure of health literacy, studies that assessed the readability of child health information, and observational or experimental studies that included a validated measure of health literacy, literacy, or numeracy skills and an assessment of child health-related outcomes. RESULTS: A total of 1267 articles were reviewed, and 215 met inclusion and exclusion criteria. At least 1 in 3 adolescents and young adults had low health literacy; most child health information was written above the tenth-grade level. Adjusted for socioeconomic status, adults with low literacy are 1.2 to 4 times more likely to exhibit negative health behaviors that affect child health, adolescents with low literacy are at least twice as likely to exhibit aggressive or antisocial behavior, and chronically ill children who have caregivers with low literacy are twice as likely to use more health services. CONCLUSIONS: Low caregiver literacy is common and is associated with poor preventive care behaviors and poor child health outcomes. Future research should aim to ameliorate literacy-associated child health disparities.

Promoting health communication between the community-dwelling well-elderly and pharmacists: the Ask Me 3 program.

OBJECTIVE: To describe readiness to use clear health communication principles with a pharmacist before and after participating in the Ask Me 3 (What is my main problem?, What do I need to do?, Why is it important for me to do this?) program. DESIGN: Modified, separate-sample, pretest-posttest study. SETTING: Senior centers in Polk County, IA, between March 2006 and February 2007. PARTICIPANTS: 106 community-dwelling well-elderly. INTERVENTION: Information on demographic characteristics, regularity of health care and medication use, health literacy level, and a measurement of multidimensional health locus of control were collected from participants, who were then were randomly allocated to one of three assessment subgroups: (1) pretest-posttest, (2) pretest only, and (3) posttest only during each of 12 Ask Me 3 program educational sessions. MAIN OUTCOME MEASURE: Readiness to use the seven principles of clear health communication described in the Ask Me 3 program. RESULTS: Participants were predominantly women and white, had a high school education or higher, had a yearly income of $25,000 or less, and had a mean age of 75.1 years. A majority reported good to excellent health status and visited their physician two or more times per year. All took medications regularly for a medical problem. A minority had inadequate to marginal health literacy. Before the Ask Me 3 program, a majority reported planning to or actively asking their pharmacist (1) for help with questions about their medications (88.2%), (2) to explain how to take their medication (82.6%), (3) to describe the main problem for which their medication is being prescribed (78.6%), and (4) to describe what can happen if they don't take their medication (74.3%). Approximately one-half of participants (55.2%) made a list of health or medication concerns to tell their pharmacist. A minority brought a list of current medications (47.8%) or brought a friend or family member to help when visiting their pharmacist (27.9%). A significantly higher proportion of participants reported planning to or actively bringing a list of current medications when visiting the pharmacist (P < or = 0.025) after participating in the Ask Me 3 program. Increases were not statistically significant for the remaining principles. CONCLUSION: The Ask Me 3 program is a practical tool that creates awareness and reinforces principles of clear health communication. The Ask Me 3 program should be evaluated in diverse pharmacy and health care settings with patients at high risk for poor health communication.