Non-high-density lipoprotein cholesterol in patients with metabolic syndrome.

BACKGROUND: Metabolic syndrome (MS) represents a cluster of cardiovascular risk factors that includes hypertriglyceridemia. Although low-density lipoprotein (LDL) cholesterol is the critical therapeutic target in patients with coronary artery disease, LDL cannot be calculated in those with excessive hypertriglyceridemia. Non-high-density lipoprotein (HDL) does not require LDL for calculation and may be an alternative therapeutic target in MS. The purpose of this study was to determine non-HDL cholesterol in relation to other lipid components and comorbidities in MS patients. METHODS: A cross-sectional chart review on 928 public hospital patients was performed. RESULTS: Metabolic syndrome was present in 53% of all patients. Among those with MS, 87% had triglyceride level of greater than 150 mg/dL, 85% had low HDL, 71% had LDL of greater than 100 mg/dL, and 74% had non-HDL of greater than 130 mg/dL. The level of non-HDL cholesterol, but not total cholesterol or LDL cholesterol, was significantly higher (P < 0.05) and less at goal (P < 0.0001) in patients with MS. Diagnoses of coronary artery disease, hypertension, obesity, dyslipidemia, and diabetes were significantly more prevalent in MS patients (P < 0.0001). CONCLUSION: Compared with those without MS, non-HDL level was significantly higher and undertargeted in patients with MS, in parallel with significantly higher prevalence of comorbidities.

Provider and patient intervention to improve weight loss: a pilot study in a public hospital clinic.

OBJECTIVE: To assess the efficacy of a literacy-appropriate weight loss intervention targeting providers and patients in improving physicians' weight loss counseling and patients' self-reported beliefs, and self-efficacy. METHODS: The study took place in a public hospital nephrology clinic. The intervention included two physician workshops and a small group patient education. Physician-patient communication was observed and coded. Structured interviews assessed patient recall of weight loss recommendations, weight-related beliefs, and self-efficacy. RESULTS: 64 patient visits were observed before and after the intervention. 75% of patients were African American, 96% lacked private insurance, 71% had low literacy skills; mean body mass index (BMI) of 35 kg/m(2). Physician counseling improved significantly post-intervention, particularly in assessing, supporting and advising patients about weight loss and exercise. Patients reported increases in recall of weight loss recommendations and were more likely to report greater confidence about losing weight (52% vs. 70%, p<0.01). CONCLUSIONS: This pilot study offers promising directions to address provider and patient barriers to weight loss education and counseling in a public hospital. PRACTICE IMPLICATIONS: Hospital-based weight loss interventions need to target both physicians and patients.

Development and validation of the Rapid Estimate of Adolescent Literacy in Medicine (REALM-Teen): a tool to screen adolescents for below-grade reading in health care settings.

OBJECTIVE: The magnitude and consequences of low literacy in adolescent health and health care are unknown. The purpose of this study was to validate the Rapid Estimate of Adolescent Literacy in Medicine (REALM-Teen), a word-recognition test in English that can be used as a brief literacy-screening tool in health care settings. PATIENTS AND METHODS: A total of 1533 adolescents aged 10 to 19 years attending 1 of 5 middle schools, 3 high schools, 1 pediatric clinic, or 2 summer programs in Louisiana and North Carolina participated in face-to-face interviews. Demographic information was solicited, and participants were administered a battery of reading tests, including the REALM-Teen, Wide Range Achievement Test-Revised (WRAT-3), and Slosson Oral Reading Test-Revised (SORT-R). Internal consistency for the REALM-Teen was determined using Cronbach's alpha, and criterion validity was established through correlations with both the WRAT-R and SORT-R. Using reading below grade level (according to SORT-R scores) as an outcome, instrument accuracy and corresponding cutoff scores were calculated by plotting receiver operating characteristic curves and stratum-specific likelihood ratios. RESULTS: Participants were 50% black and 53% female; 34% were enrolled in middle school and 66% in high school. The average time required to administer the REALM-Teen was 3 minutes. Internal consistency was excellent, as was test-retest reliability. The REALM-Teen is strongly correlated with both the WRAT-R and SORT-R. Five reading level categories were identified: 3rd grade and below, 4th to 5th grade, 6th to 7th grade, 8th to 9th grade, and 10th grade and above. Forty-six percent of participants were reading below grade level according to the SORT-R and 28% had repeated at least 1 grade. CONCLUSION: The REALM-Teen is a brief, reliable instrument for assessing adolescent literacy skills and reading below grade level.

Low literacy impairs comprehension of prescription drug warning labels.

BACKGROUND: Adverse events resulting from medication error are a serious concern. Patients' literacy and their ability to understand medication information are increasingly seen as a safety issue. OBJECTIVE: To examine whether adult patients receiving primary care services at a public hospital clinic were able to correctly interpret commonly used prescription medication warning labels. DESIGN: In-person structured interviews with literacy assessment. SETTING: Public hospital, primary care clinic. PARTICIPANTS: A total of 251 adult patients waiting for an appointment at the Louisiana State University Health Sciences Center in Shreveport (LSUHSC-S) Primary Care Clinic. MEASUREMENTS: Correct interpretation, as determined by expert panel review of patients' verbatim responses, for each of 8 commonly used prescription medication warning labels. RESULTS: Approximately one-third of patients (n=74) were reading at or below the 6th-grade level (low literacy). Patient comprehension of warning labels was associated with one's literacy level. Multistep instructions proved difficult for patients across all literacy levels. After controlling for relevant potential confounding variables, patients with low literacy were 3.4 times less likely to interpret prescription medication warning labels correctly (95% confidence interval: 2.3 to 4.9). CONCLUSIONS: Patients with low literacy had difficulty understanding prescription medication warning labels. Patients of all literacy levels had better understanding of warning labels that contained single-step versus multiple-step instructions. Warning labels should be developed with consumer participation, especially with lower literate populations, to ensure comprehension of short, concise messages created with familiar words and recognizable icons.

Vaccine risk/benefit communication: effect of an educational package for public health nurses.

The purpose of this study was to determine whether an in-service for public health nurses (PHNs) and accompanying educational materials could improve vaccine risk/benefit communication. The content and timing of vaccine communication were recorded during 246 pre-and 217 postintervention visits in two public health immunization clinics. Pre-/postintervention comparisons showed PHN communication of severe side effects (13% vs. 44%, p < .0001) and their management (29% vs. 60%, p < .0001) increased. There was no significant change in discussion of vaccine benefits (48% vs. 51%) or common side effects (91% vs. 92%),screening for contraindications (71% vs. 77%), or distribution of written information (89% vs. 92%). More parents initiated vaccine questions postintervention (27% vs. 39%,p < .01) and were more satisfied with vaccine-risk communication (8.1 vs. 8.9 on a 10-point scale, p < .01). Average vaccine communication time increased from 16 to 22 seconds (p < .01).

Assessment of newborn screening parent education materials.

OBJECTIVE: The purpose of this study was to measure the readability and user-friendliness (clarity, complexity, organization, appearance, and cultural appropriateness of materials) of parent education brochures on newborn screening. METHODS: We studied English-language versions of the brochures that state newborn screening programs prepare and distribute. We obtained brochures from 48 states and Puerto Rico. We evaluated each brochure for readability with the Flesch reading ease formula. User-friendliness of the brochures was assessed with an instrument we created that contained 22 specific criteria grouped into 5 categories, ie, layout, illustrations, message, manageable information, and cultural appropriateness. RESULTS: Most current newborn screening brochures should be revised to make them more readable and user-friendly for parents. Ninety-two percent of brochures were written at a reading level that is higher than the average reading level of US adults (eighth-grade level). In most brochures, the essential information for parents was buried. Although all brochures were brief and focused on the newborn screening tests being performed, 81% needed improvement in getting to the point quickly and making it easy for parents to identify what they needed to know or to do. None of the brochures scored high in all 22 criteria on the user-friendliness checklist. CONCLUSIONS: Parent education materials about newborn screening should be revised to be easier to read and more user-friendly, by lowering the reading difficulty to eighth-grade level and focusing on issues such as layout, illustrations, message, information, and cultural appropriateness. It is important that state newborn screening programs and organizations work with parents to develop and to evaluate materials to ensure that they are user-friendly.

Recommendations for effective newborn screening communication: results of focus groups with parents, providers, and experts.

OBJECTIVES: The aims of this study were to determine parent and provider knowledge and awareness of newborn screening; to gather opinions from parents, providers, and newborn screening professionals about the content and timing of newborn screening education; and to use consensus data to formulate recommendations and to develop educational materials for parents and providers. METHODS: We conducted 22 focus groups and 3 individual interviews between October 2003 and May 2004, with English- and Spanish-speaking parents of infants <1 year of age who had experience with initial testing, retesting, or false-positive screenings; health professionals who provide prenatal care or health care for newborns; and state newborn screening program health professionals. RESULTS: Parents and providers had limited knowledge and awareness about newborn screening practices. Parents wanted brief to-the-point information on newborn screening and its benefits, including the possible need for retesting and the importance of returning promptly for retesting if initial results are abnormal. Parents wanted the information orally from the primary care provider. Parents, providers, and newborn screening professionals all thought that an accompanying concise, easy-to-read brochure with contact information would be helpful. All focus group participants thought that parents should receive this information before the birth of the infant, preferably in the third trimester of pregnancy. Providers wanted a brief checklist of information and resources to prepare them to educate parents effectively. CONCLUSIONS: We recommend prenatal and primary care providers be more involved in educating parents about newborn screening. Professional societies and state health officials should work together to encourage parent and provider education. User-friendly patient and provider education materials, such as those we developed, could form the basis for this educational approach.

Infant hearing screening: stakeholder recommendations for parent-centered communication.

OBJECTIVES: The purpose of this study was to identify what stakeholders considered best practices for parent-provider communication regarding newborn hearing screening and diagnosis. We used consensus data to develop educational materials for parents. METHODS: We conducted 29 focus groups and 23 individual interviews between October 2003 and May 2004. Participants included (1) English- and Spanish-speaking parents of infants <18 months of age who had experience with hospital-based newborn hearing screening; (2) parents of children with hearing loss; (3) primary care providers who provide prenatal care or care for newborns; and (4) audiologists, audiology technicians, and hospital nurses. RESULTS: Communication to parents about hospital-based newborn hearing screening was limited. Most parents first learned about the screening in the hospital, but all stakeholders thought a more opportune time for education was before the birth. For parents of infants who did not pass the newborn hearing screening, stakeholders recommended direct communication about the urgency of diagnostic testing. They also indicated that primary care providers needed current information regarding hearing screening, diagnostic testing, and early intervention. All stakeholders thought that a brief brochure for parents to take home would be helpful for hospital-based screening and, if necessary, subsequent diagnostic testing. Primary care providers requested basic, to-the-point information. CONCLUSIONS: The most opportune time to begin discussion of newborn hearing screening is before the birth. Providers need up-to-date information on current standards of hearing screening, diagnosis, and intervention. User-friendly patient education materials, such as those we developed, could assist providers in educating parents.

Tipping the scales: the effect of literacy on obese patients' knowledge and readiness to lose weight.

OBJECTIVES: The purpose of this study was to determine the association between the literacy level of overweight/obese patients and their weight-loss knowledge, attitudes, and readiness. METHODS: Structured patient interviews and a literacy screening instrument were administered in two primary care clinics at a university-based public hospital. RESULTS: A convenience sample of 210 overweight or obese adult outpatients (body mass index > or =25 kg/m2 or > or =30 kg/m2, respectively) were enrolled. Mean respondent age was 52 years; 74% were female, and 76% were black. Two thirds of patients read below a 9th grade level. Half of patients across all literacy levels reported currently attempting weight loss. There was a significant relation between literacy level and weight-loss knowledge, attitudes, and readiness (P < 0.05). CONCLUSIONS: Patients with low literacy were significantly less likely to understand the adverse health consequences of obesity and the need to lose weight and to report being ready to lose weight. Patient education and counseling for weight loss should be tailored for patients with low literacy skills.

Childhood immunization refusal: provider and parent perceptions.

BACKGROUND AND OBJECTIVES: Parental concerns may contribute to immunization refusals and low infant immunization rates. Little knowledge is available about how often and why parents refuse immunizations for their children. This study was conducted to estimate, based on reports from health care providers and parents, the frequency of and reasons for immunization refusal. METHODS: In 1998, we conducted 32 focus groups of parents and providers in six cities. We then mailed a survey to a random sample of private practice family physicians and pediatricians and public health nurses who immunize children. The overall survey response rate was 77%, and the final sample size was 544. RESULTS: Focus group findings indicated that parents rarely refused vaccines but occasionally resisted specific vaccines. Parents who were unsure about vaccinating were open to discussions about vaccines with a trusted provider. Most of these parents agreed to immunize after discussing concerns with their provider. In a subsequent survey of providers, respondents estimated that they immunized a mean of 3536 (median 1560) children annually. The reported mean number of refusals per 1000 children age >18 years immunized was 7.2 (median 0.4), with varicella vaccine being the most commonly refused. Means did not vary by region or specialty. Providers indicated that fear of side effects heard about from media/word of mouth was the most commonly expressed reason for parents to refuse vaccines (52%). Religious (28%) or philosophical (26%) reasons or belief that the disease was not harmful (26%) were less common reasons. Providers reported that few parents refused because of anti-government sentiment (8%). CONCLUSIONS: Providers indicate low vaccine refusal rates within offices of traditional primary care providers and in public health clinics. Strategies for efficient provider-patient communication are needed to address parental concerns about vaccines.

Childhood vaccine risk/benefit communication among public health clinics: a time-motion study.

United States law requires that immunization providers use Centers for Disease Control Vaccine Information Statements (VISs) and inform parents about vaccine risks and benefits prior to every childhood immunization. A recent national survey found that public health clinics (PHCs) reported high compliance with this law. To further investigate these findings, we conducted an immunization time-motion study in two PHCs in Kansas and Louisiana. Research assistants observed a convenience sample of 246 child immunization visits to record distribution of the VISs and content and time of vaccine communication. Thirty percent of parents read below a ninth grade level, 53% had Medicaid insurance, and 56% were Black. VISs were given with every dose of vaccine administered in 89% of visits. Public health nurses (PHNs) frequently discussed potential vaccine side effects (91%), treatment of side effects (91%), and the vaccine schedule (93%). Contraindications were screened in 71% of visits. Benefits were discussed in 48% of visits and severe risks in 29%. The national Vaccine Injury Compensation Program (VICP) was never discussed. The immunization visits lasted for a mean of 20 min. Vaccine communication of side effects, risks, benefits, screening for contraindications, and the next visit lasted for an average of 16 s for all vaccines. PHC compliance with mandated VIS distribution and practical vaccine communication was high. Room for improvement exists in discussion of benefits, serious risks, and the VICP.