Language Disparities in Caregiver Satisfaction with Physician Communication at Well Visits from 0-2 Years.

OBJECTIVE: This study aimed to describe caregiver satisfaction with physician communication over the first two years of life and examine differences by preferred language and the relationship to physician continuity. METHODS: Longitudinal data were collected at well visits (2 months to 2 years) from participants in a randomized controlled trial to prevent childhood obesity. Satisfaction with communication was assessed using the validated Communication Assessment Tool (CAT) questionnaire. Changes in the odds of optimal scores were estimated in mixed-effects logistic regression models to evaluate the associations between satisfaction over time and language, interpreter use, and physician continuity. RESULTS: Of 865 caregivers, 35% were Spanish-speaking. Spanish-speaking caregivers without interpreters had lower odds of an optimal satisfaction score compared with English speakers during the first 2 years, beginning at 2 months [OR 0.64 (95% CI: 0.43, 0.95)]. There was no significant difference in satisfaction between English-speaking caregivers and Spanish-speaking caregivers with an interpreter. The odds of optimal satisfaction scores increased over time for both language groups. For both language groups, odds of an optimal satisfaction score decreased each time a new physician was seen for a visit [OR 0.82 (95% CI: 0.69, 0.97)]. CONCLUSION: Caregiver satisfaction with physician communication improves over the first two years of well-child visits for both English- and Spanish-speakers. A loss of physician continuity over time was also associated with lower satisfaction. Future interventions to ameliorate communication disparities should ensure adequate interpreter use for primarily Spanish-speaking patients and address continuity issues to improve communication satisfaction.

Avenues for Strengthening PCORnet's Capacity to Advance Patient-Centered Economic Outcomes in Patient-Centered Outcomes Research (PCOR).

PCORnet, the National Patient-Centered Clinical Research Network, provides the ability to conduct prospective and observational pragmatic research by leveraging standardized, curated electronic health records data together with patient and stakeholder engagement. PCORnet is funded by the Patient-Centered Outcomes Research Institute (PCORI) and is composed of 8 Clinical Research Networks that incorporate at total of 79 health system "sites." As the network developed, linkage to commercial health plans, federal insurance claims, disease registries, and other data resources demonstrated the value in extending the networks infrastructure to provide a more complete representation of patient's health and lived experiences. Initially, PCORnet studies avoided direct economic comparative effectiveness as a topic. However, PCORI's authorizing law was amended in 2019 to allow studies to incorporate patient-centered economic outcomes in primary research aims. With PCORI's expanded scope and PCORnet's phase 3 beginning in January 2022, there are opportunities to strengthen the network's ability to support economic patient-centered outcomes research. This commentary will discuss approaches that have been incorporated to date by the network and point to opportunities for the network to incorporate economic variables for analysis, informed by patient and stakeholder perspectives. Topics addressed include: (1) data linkage infrastructure; (2) commercial health plan partnerships; (3) Medicare and Medicaid linkage; (4) health system billing-based benchmarking; (5) area-level measures; (6) individual-level measures; (7) pharmacy benefits and retail pharmacy data; and (8) the importance of transparency and engagement while addressing the biases inherent in linking real-world data sources.

Prenatal Risks to Healthy Food Access and High Birthweight Outcomes.

OBJECTIVE: Infants with high birthweight have increased risk for adverse outcomes at birth and across childhood. Prenatal risks to healthy food access may increase odds of high birthweight. We tested whether having a poor neighborhood food environment and/or food insecurity had associations with high birthweight. METHODS: We analyzed cross-sectional baseline data in Greenlight Plus, an obesity prevention trial across six US cities (n = 787), which included newborns with a gestational age greater than 34 weeks and a birthweight greater than 2500 g. We assessed neighborhood food environment using the Place-Based Survey and food insecurity using the US Household Food Security Module. We performed logistic regression analyses to assess the individual and additive effects of risk factors on high birthweight. We adjusted for potential confounders: infant sex, race, ethnicity, gestational age, birthing parent age, education, income, and study site. RESULTS: Thirty-four percent of birthing parents reported poor neighborhood food environment and/or food insecurity. Compared to those without food insecurity, food insecure families had greater odds of delivering an infant with high birthweight (adjusted odds ratios [aOR] 1.96, 95% confidence intervals [CI]: 1.01, 3.82) after adjusting for poor neighborhood food environment, which was not associated with high birthweight (aOR 1.35, 95% CI: 0.78, 2.34). Each additional risk to healthy food access was associated with a 56% (95% CI: 4%-132%) increase in high birthweight odds. CONCLUSIONS: Prenatal risks to healthy food access may increase high infant birthweight odds. Future studies designed to measure neighborhood factors should examine infant birthweight outcomes in the context of prenatal social determinants of health.

Many Medicare Beneficiaries Do Not Fill High-Price Specialty Drug Prescriptions.

For high-price drugs, Medicare Part D beneficiaries who do not receive a low-income subsidy must pay a percentage of the drug's price for each medication fill. Without that subsidy, which lowers out-of-pocket spending, beneficiaries typically pay hundreds or thousands of dollars for a single fill. We estimated the proportion of Part D beneficiaries in fee-for-service Medicare, with and without a subsidy, who do not initiate treatment (that is, do not fill a new prescription) with high-price Part D drugs newly prescribed for four conditions. Examining 17,076 new prescriptions issued between 2012 and 2018 for Part D beneficiaries from eleven geographically diverse health systems, we found that beneficiaries receiving subsidies were nearly twice as likely to obtain the prescribed drug within ninety days as those without subsidies. Among beneficiaries without subsidies, we observed noninitiation for 30 percent of prescriptions written for anticancer drugs, 22 percent for hepatitis C treatments, and more than 50 percent for disease-modifying therapies for either immune system disorders or hypercholesterolemia. Our findings support current legislative efforts to increase the accessibility of high-price medications by reducing out-of-pocket expenses under Medicare Part D, particularly for beneficiaries without low-income subsidies.

Racial and Ethnic Differences in Maternal Social Support and Relationship to Mother-Infant Health Behaviors.

OBJECTIVE: To examine racial and ethnic differences in maternal social support in infancy and the relationship between social support and mother-infant health behaviors. METHODS: Secondary analysis of baseline data from a multisite obesity prevention trial that enrolled mothers and their 2-month-old infants. Behavioral and social support data were collected via questionnaire. We used modified Poisson regression to determine association between health behaviors and financial and emotional social support, adjusted for sociodemographic characteristics. RESULTS: Eight hundred and twenty-six mother-infant dyads (27.3% non-Hispanic Black, 18.0% Non-Hispanic White, 50.1% Hispanic and 4.6% Non-Hispanic Other). Half of mothers were born in the United States; 87% were Medicaid-insured. There were no racial/ethnic differences in social support controlling for maternal nativity. US-born mothers were more likely to have emotional and financial support (rate ratio [RR] 1.14 95% confidence interval [CI]: 1.07, 1.21 and RR 1.23 95% CI: 1.11, 1.37, respectively) versus mothers born outside the United States. Mothers with financial support were less likely to exclusively feed with breast milk (RR 0.62; 95% CI: 0.45, 0.87) yet more likely to have tummy time ≥12min (RR 1.28; 95% CI: 1.02, 1.59) versus mothers without financial support. Mothers with emotional support were less likely to report feeding with breast milk (RR 0.82; 95% CI: 0.69, 0.97) versus mothers without emotional support. CONCLUSIONS: Nativity, not race or ethnicity, is a significant determinant of maternal social support. Greater social support was not universally associated with healthy behaviors. Interventions may wish to consider the complex nature of social support and population-specific social support needs.

User preferences for and engagement with text messages to support antihypertensive medication adherence: Findings from a pilot study evaluating an emergency department-based behavioral intervention.

OBJECTIVE: We examined users' preferences for and engagement with text messages delivered as part of an emergency department (ED)-based intervention to improve antihypertensive medication adherence. METHODS: We recruited ED patients with elevated blood pressure for a pilot randomized trial evaluating a medication adherence intervention with text messages. Intervention participants chose text content and frequency, received texts for 45 days, and completed a feedback survey. We defined engagement via responses to texts. We examined participant characteristics associated with text preferences, engagement, and feedback. RESULTS: Participants (N = 101) were 57% female and 46% non-White. Most participants (71%) chose to receive both reminder and informational texts; 94% chose reminder texts once per day and 97% chose informational texts three times per week. Median text message response rate was 56% (IQR 26-80%). Participants who were Black (p < 0.01), had lower income (p = 0.03), or had lower medication adherence (p < 0.01) rated the program as more helpful and wanted additional functionalities for adherence support. CONCLUSIONS AND PRACTICE IMPLICATIONS: While overall engagement was modest, participants at risk of worse health outcomes expressed more value and interest in the program. Findings inform the design of text messaging interventions for antihypertensive medication adherence and support targeting vulnerable patients to reduce health disparities. CLINICAL TRIALS REGISTRATION: NCT02672787.

Patient-Reported Outcome Measures in Colon and Rectal Surgery: A Systematic Review and Quality Assessment.

BACKGROUND: There is growing interest in using patient-reported outcome measures to support value-based care in colorectal surgery. To draw valid conclusions regarding patient-reported outcomes data, measures with robust measurement properties are required. OBJECTIVE: The purpose of this study was to assess the use and quality of patient-reported outcome measures in colorectal surgery. DATA SOURCES: Three major databases were searched for studies using patient-reported outcome measures in the context of colorectal surgery. STUDY SELECTION: Articles that used patient-reported outcome measures as outcome for colorectal surgical intervention in a comparative effectiveness analysis were included. Exclusion criteria included articles older than 11 years, non-English language, age <18 years, fewer than 40 patients, case reports, review articles, and studies without comparison. MAIN OUTCOME MEASURES: This was a quality assessment using a previously reported checklist of psychometric properties. RESULTS: From 2007 to 2018, 368 studies were deemed to meet inclusion criteria. These studies used 165 distinct patient-reported outcome measures. Thirty were used 5 or more times and were selected for quality assessment. Overall, the measures were generally high quality, with 21 (70%) scoring ≥14 on an 18-point scale. Notable weaknesses included management of missing data (14%) and description of literacy level (0%). LIMITATIONS: The study was limited by its use of original articles for quality assessment. Measures were selected for quality analysis based on frequency of use rather than other factors, such as impact of the article or number of patients in the study. CONCLUSIONS: Patient-reported outcome measures are widely used in colorectal research. There was a wide range of measures available, and many were used only once. The most frequently used measures are generally high quality, but a majority lack details on how to deal with missing data and information on literacy levels. As the use of patient-reported outcome measures to assess colorectal surgical intervention increases, researchers and practitioners need to become more knowledgeable about the measures available and their quality.

Parental Feeding Beliefs and Practices and Household Food Insecurity in Infancy.

OBJECTIVE: Food insecurity is associated with childhood obesity possibly mediated through caregiver feeding practices and beliefs. We examined if caregiver feeding practices differed by household food security status in a diverse sample of infants. We hypothesized that feeding practices differ based on food security status. PATIENTS AND METHODS: Included in the baseline cross-sectional analysis of data from a randomized controlled trial to prevent obesity were 842 caregivers of 2-month-old infants presenting for well-child care at 4 academic institutions. Food insecurity exposure was based on an affirmative answer to 1 of 2 items in a 2-item validated questionnaire. Chi-square tests examined the association between parent feeding practices and food security status. Logistic regression adjusted for covariates. Differences in caregiver feeding practices by food security status and race/ethnicity were explored with an interaction term (food security status x race/ethnicity). RESULTS: Forty-three percent of families screened as food insecure. In adjusted logistic regression, parents from food-insecure households were more likely to endorse that "the best way to make an infant stop crying is to feed him or her" (adjusted odds ratio [aOR], 1.72; 95% confidence interval [CI], 1.28-2.29) and "when my baby cries, I immediately feed him or her" (aOR, 1.40; 95% CI, 1.06-1.83). Food-insecure caregivers less frequently endorsed paying attention to their baby when he or she is full or hungry (OR, 0.57; 95% CI, 0.34-0.96). Racial/ethnic differences in beliefs and behaviors were observed by food security status. CONCLUSIONS: During early infancy, feeding practices differed among caregivers by household food security status. Further research is needed to examine whether these practices are associated with increased risk of obesity and obesity-related morbidity.

Text Messaging May Engage and Benefit Adults with Type 2 Diabetes Regardless of Health Literacy Status.

BACKGROUND: Technology-delivered interventions have the potential to improve diabetes self-care and glycemic control among adults with type 2 diabetes (T2D). However, patients who do not engage with interventions may not reap benefits, and there is little evidence on how engagement with mobile health interventions varies by health literacy status. OBJECTIVE: This study explored how patients with limited health literacy engaged with and experienced Rapid Education/Encouragement and Communications for Health (REACH), a text messaging intervention designed to support the self-care adherence of disadvantaged patients with T2D. We recruited adults with T2D from federally qualified health centers and used mixed methods to examine (1) associations between users' health literacy status and their prior mobile phone use and their engagement with REACH and (2) similarities and differences in users' self-reported benefits by health literacy status. METHODS: Participants (N = 55) completed a survey, including measures of health literacy and prior mobile phone use. For 2 weeks, participants experienced REACH, which included daily text messages promoting self-care and asking about medication adherence, and weekly text messages providing medication adherence feedback. After 2 weeks, participants completed a semi-structured telephone interview about their experiences. KEY RESULTS: Participants with limited health literacy were less likely to have used cell phones to access the Internet (48% vs. 90%, p = .001) or email (36% vs. 87%, p < .001), but equally as likely to have used text messaging and to respond to REACH text messages (p = .12 and p = .40, respectively) compared to participants with adequate health literacy. Participants responded to 93% of text messages on average and reported benefits of the intervention, including reminders and accountability, convenience and accessibility, and information and motivation. Participants with limited health literacy described a unique benefit of receiving social support from the intervention. CONCLUSIONS: Text messaging interventions may engage and benefit patients with T2D, regardless of health literacy status. Text messaging may have the potential to reduce T2D health disparities related to limited health literacy.

Recruitment methods for survey research: Findings from the Mid-South Clinical Data Research Network.

PURPOSE: The objective of this study was to report survey response rates and demographic characteristics of eight recruitment approaches to determine acceptability and effectiveness of large-scale patient recruitment among various populations. METHODS: We conducted a cross sectional analysis of survey data from two large cohorts. Patients were recruited from the Mid-South Clinical Data Research Network using clinic-based recruitment, research registries, and mail, phone, and email approaches. Response rates are reported as patients who consented for the survey divided by the number of eligible patients approached. RESULTS: We contacted more than 90,000 patients and 13,197 patients completed surveys. Median age was 56.3years (IQR 40.9, 67.4). Racial/ethnic distribution was 84.1% White, non-Hispanic; 9.9% Black, non-Hispanic; 1.8% Hispanic; and 4.0% other, non-Hispanic. Face-to-face recruitment had the highest response rate of 94.3%, followed by participants who "opted-in" to a registry (76%). The lowest response rate was for unsolicited emails from the clinic (6.1%). Face-to-face recruitment enrolled a higher percentage of participants who self-identified as Black, non-Hispanic compared to other approaches (18.6% face-to-face vs. 8.4% for email). CONCLUSIONS: Technology-enabled recruitment approaches such as registries and emails are effective for recruiting but may yield less racial/ethnic diversity compared to traditional, more time-intensive approaches.

Systolic Blood Pressure and Biochemical Assessment of Adherence: A Cross-Sectional Analysis in the Emergency Department.

Elevated blood pressure (BP) is common in the emergency department (ED), but the relationship between antihypertensive medication adherence and BP in the ED is unclear. This cross-sectional study tested the hypothesis that higher antihypertensive adherence is associated with lower systolic BP (SBP) in the ED among adults with hypertension who sought ED care at an academic hospital from July 2012 to April 2013. Biochemical assessment of antihypertensive adherence was performed using a mass spectrometry blood assay, and the primary outcome was average ED SBP. Analyses were stratified by number of prescribed antihypertensives (<3, ≥3) and adjusted for age, sex, race, insurance, literacy, numeracy, education, body mass index, and comorbidities. Among 85 patients prescribed ≥3 antihypertensives, mean SBP for adherent patients was 134.4 mm Hg (±26.1 mm Hg), and in adjusted analysis was -20.8 mm Hg (95% confidence interval, -34.2 to -7.4 mm Hg; P=0.003) different from nonadherent patients. Among 176 patients prescribed <3 antihypertensives, mean SBP was 135.5 mm Hg (±20.6 mm Hg) for adherent patients, with no difference by adherence in adjusted analysis (+2.9 mm Hg; 95% confidence interval, -4.7 to 10.5 mm Hg; P=0.45). Antihypertensive nonadherence identified by biochemical assessment was common and associated with higher SBP in the ED among patients who had a primary care provider and health insurance and who were prescribed ≥3 antihypertensives. Biochemical assessment of antihypertensives could help distinguish medication nonadherence from other contributors to elevated BP and identify target populations for intervention.

Association Between Bottle Size and Formula Intake in 2-Month-Old Infants.

OBJECTIVE: To determine range of bottle sizes used and examine the relationship between bottle size and total daily consumption of infant formula. METHODS: Cross-sectional analysis of baseline data collected as part of Greenlight, a cluster randomized trial to prevent childhood obesity at 4 pediatric resident clinics. The Greenlight study included healthy, term infants. For our analysis, parents of exclusively formula-fed infants reported volume per feed, number of feeds per day, and bottle size, which was dichotomized into small (<6 oz) or large (≥6 oz). We identified determinants of bottle size, and then examined relationships between bottle size and volume fed with log-transformed ordinary least squares regression, adjusting for infant age, sex, birth weight, current weight, race/ethnicity, and enrollment in Special Supplemental Nutrition Program for Women, Infants, and Children. RESULTS: Of 865 participants in the Greenlight study, 44% (n = 378; 21.8% white, 40.6% black, 35.3% Hispanic, 2.4% other) of infants were exclusively formula fed at 2 months. Median volume per day was 30 oz (interquartile range 12), and 46.0% of infants were fed with large bottles. Adjusted for covariates, parents using larger bottles reported feeding 4 oz more formula per day (34.2 oz, 95% confidence interval 33.5-34.9 vs 29.7 oz, 95% confidence interval 29.2-30.3, P = .03). CONCLUSIONS: Among exclusively formula-fed infants, use of a larger bottle is associated with parental report of more formula intake compared to infants fed with smaller bottles. If infants fed with larger bottles receive more formula, these infants may be overfed and consequently at risk for obesity.

Improved self-management skills in Chinese diabetes patients through a comprehensive health literacy strategy: study protocol of a cluster randomized controlled trial.

BACKGROUND: Diabetes self-management often involves the interpretation and application of oral, written, or quantitative information. Numerous diabetes patients in China have limited health literacy, which likely leads to poorer clinical outcomes. This study is designed to examine the efficacy and cost-effectiveness of addressing health literacy to improve self-management skills and glycemic control in Chinese diabetes patients. METHODS/DESIGN: This is a cluster randomized controlled trial (RCT) conducted in 20 community healthcare sites in Shanghai, China. Overall, 800 diabetes patients will be randomized into intervention and control arms and will have a baseline hemoglobin A1c (HbA1c) assay and undergo a baseline survey which includes measures of health literacy and diabetes numeracy using revised Chinese versions of the Health Literacy Management Scale and Diabetes Numeracy Test Scale. During the 1-year period of intervention, while the control group will receive usual care, the intervention group will be supplemented with a comprehensive health literacy strategy which includes i) training healthcare providers in effective health communication skills that address issues related to low literacy, and ii) use of an interactive Diabetes Education Toolkit to improve patient understanding and behaviors. Assessments will be conducted at both patient and healthcare provider levels, and will take place upon admission and after 3, 6, 12, and 24 months of intervention. The primary outcome will be the improvement in HbA1c between Intervention group and Control group patients. Secondary outcomes at the patient level will include improvement in i) clinical outcomes (blood pressure, fasting lipids, body mass index, weight, smoking status), ii) patient reported self-management behaviors, and iii) patient-reported self-efficacy. Outcomes at the provider level will include: i) provider satisfaction and ii) intensity and type of care provided. The effects of the intervention will be examined in multivariable general linear models. Both cost-effectiveness and cost-utility analyses will be performed. DISCUSSION: The main strengths of this study are its large sample size and RCT design, involvement of both patients and healthcare providers, and the long term follow-up (24-months). This project will help to demonstrate the value of addressing health literacy and health communication to improve self-management and clinical outcomes among Chinese diabetes patients. TRIAL REGISTRATION: ISRCTN76130594, Registration date: Sept 22, 2014.

The Mid-South clinical Data Research Network.

The Mid-South Clinical Data Research Network (CDRN) encompasses three large health systems: (1) Vanderbilt Health System (VU) with electronic medical records for over 2 million patients, (2) the Vanderbilt Healthcare Affiliated Network (VHAN) which currently includes over 40 hospitals, hundreds of ambulatory practices, and over 3 million patients in the Mid-South, and (3) Greenway Medical Technologies, with access to 24 million patients nationally. Initial goals of the Mid-South CDRN include: (1) expansion of our VU data network to include the VHAN and Greenway systems, (2) developing data integration/interoperability across the three systems, (3) improving our current tools for extracting clinical data, (4) optimization of tools for collection of patient-reported data, and (5) expansion of clinical decision support. By 18 months, we anticipate our CDRN will robustly support projects in comparative effectiveness research, pragmatic clinical trials, and other key research areas and have the capacity to share data and health information technology tools nationally.

Determinants of health after hospital discharge: rationale and design of the Vanderbilt Inpatient Cohort Study (VICS).

BACKGROUND: The period following hospital discharge is a vulnerable time for patients when errors and poorly coordinated care are common. Suboptimal care transitions for patients admitted with cardiovascular conditions can contribute to readmission and other adverse health outcomes. Little research has examined the role of health literacy and other social determinants of health in predicting post-discharge outcomes. METHODS: The Vanderbilt Inpatient Cohort Study (VICS), funded by the National Institutes of Health, is a prospective longitudinal study of 3,000 patients hospitalized with acute coronary syndromes or acute decompensated heart failure. Enrollment began in October 2011 and is planned through October 2015. During hospitalization, a set of validated demographic, cognitive, psychological, social, behavioral, and functional measures are administered, and health status and comorbidities are assessed. Patients are interviewed by phone during the first week after discharge to assess the quality of hospital discharge, communication, and initial medication management. At approximately 30 and 90 days post-discharge, interviewers collect additional data on medication adherence, social support, functional status, quality of life, and health care utilization. Mortality will be determined with up to 3.5 years follow-up. Statistical models will examine hypothesized relationships of health literacy and other social determinants on medication management, functional status, quality of life, utilization, and mortality. In this paper, we describe recruitment, eligibility, follow-up, data collection, and analysis plans for VICS, as well as characteristics of the accruing patient cohort. DISCUSSION: This research will enhance understanding of how health literacy and other patient factors affect the quality of care transitions and outcomes after hospitalization. Findings will help inform the design of interventions to improve care transitions and post-discharge outcomes.

Relationship between physical inactivity and health characteristics among participants in an employee-wellness program.

OBJECTIVE: To characterize factors associated with physical inactivity among employees with access to workplace wellness program. METHODS: We examined data on physical inactivity, defined as exercise less than once a week, from the 2010 health risk assessment completed by employees at a major academic institution (N = 16,976). RESULTS: Among employees, 18% of individuals reported physical activity less than once a week. Individuals who were physically inactive as compared with physically active reported higher prevalence of cardiovascular diseases (adjusted odds ratio [AOR], 1.36 [1.23 to 1.51]), fair or poor health status (AOR, 3.52 [2.97 to 4.17]), and absenteeism from work (AOR, 1.59 [1.41 to 1.79]). Overall, physically inactive employees as compared with physically active employees reported more interest in health education programs. CONCLUSION: Future research is needed to address barriers to physical inactivity to improve employee wellness and potentially lower health utility costs.

Development and validation of the General Health Numeracy Test (GHNT).

OBJECTIVE: Because existing numeracy measures may not optimally assess 'health numeracy', we developed and validated the General Health Numeracy Test (GHNT). METHODS: An iterative pilot testing process produced 21 GHNT items that were administered to 205 patients along with validated measures of health literacy, objective numeracy, subjective numeracy, and medication understanding and medication adherence. We assessed the GHNT's internal consistency reliability, construct validity, and explored its predictive validity. RESULTS: On average, participants were 55.0 ± 13.8 years old, 64.9% female, 29.8% non-White, and 51.7% had incomes ≤$39K with 14.4 ± 2.9 years of education. Psychometric testing produced a 6-item version (GHNT-6). The GHNT-21 and GHNT-6 had acceptable-good internal consistency reliability (KR-20=0.87 vs. 0.77, respectively). Both versions were positively associated with income, education, health literacy, objective numeracy, and subjective numeracy (all p<.001). Furthermore, both versions were associated with participants' understanding of their medications and medication adherence in unadjusted analyses, but only the GHNT-21 was associated with medication understanding in adjusted analyses. CONCLUSIONS: The GHNT-21 and GHNT-6 are reliable and valid tools for assessing health numeracy. PRACTICE IMPLICATIONS: Brief, reliable, and valid assessments of health numeracy can assess a patient's numeracy status, and may ultimately help providers and educators tailor education to patients.

The association of acculturation and health literacy, numeracy and health-related skills in Spanish-speaking caregivers of young children.

Little is known about the relationship among acculturation, literacy, and health skills in Latino caregivers of young children. Latino caregivers of children < 30 months seeking primary care at four medical centers were administered measures of acculturation (SASH), functional health literacy (STOFHLA), numeracy (WRAT-3) and health-related skills (PHLAT Spanish). Child anthropomorphics and immunization status were ascertained by chart review. Caregivers (N = 184) with a median age of 27 years (IQR: 23-32) participated; 89.1% were mothers, and 97.1% had low acculturation. Lower SASH scores were significantly correlated (P < 0.01) with lower STOFHLA (ρ = 0.21), WRAT-3 (ρ = 0.25), and PHLAT Spanish scores (ρ = 0.34). SASH scores predicted PHLAT Spanish scores in a multivariable linear regression model that adjusted for the age of child, the age and gender of the caregiver, number of children in the family, the type of health insurance of the caregiver, and study site (adjusted ß: 0.84, 95% CI 0.26-1.42, P = 0.005). This association was attenuated by the addition of literacy (adjusted ß: 0.66, 95% CI 0.11-1.21, P = 0.02) or numeracy (adjusted ß: 0.50, 95% CI -0.04-1.04, P = 0.07) into the model. There was no significant association between acculturation and up-to-date child immunizations or a weight status of overweight/obese. Lower acculturation was associated with worse health literacy and diminished ability to perform child health-related skills. Literacy and numeracy skills attenuated the association between acculturation and child health skills. These associations may help to explain some child health disparities in Latino communities.

Addressing poor retention of infants exposed to HIV: a quality improvement study in rural Mozambique.

OBJECTIVE: Early infant diagnosis (EID) is the first step in HIV care, yet 75% of HIV-exposed infants born at 2 hospitals in Mozambique failed to access EID. DESIGN: Before/after study. SETTING: Two district hospitals in rural Mozambique. PARTICIPANTS: HIV-infected mother/HIV-exposed infant pairs (n = 791). INTERVENTION: We planned 2 phases of improvement using quality improvement methods. In phase 1, we enhanced referral by offering direct accompaniment of new mothers to the EID suite, increasing privacy, and opening a medical record for infants before postpartum discharge. In phase 2, we added enhanced referral activity as an item on the maternity register to standardize the process of referral. MAIN OUTCOME MEASURE: The proportion of HIV-infected mothers who accessed EID for their infant <90 days of life. RESULTS: We tracked mother/infant pairs from June 2009 to March 2011 (phase 0: n = 144; phase 1: n = 479; phase 2: n = 168), compared study measures for mother/infant pairs across intervention phases with χ², estimated time-to-EID by Kaplan-Meier, and determined the likelihood of EID by Cox regression after adjusting for likely barriers to follow-up. At baseline (phase 0), 25.7% of infants accessed EID <90 days. EID improved to 32.2% after phase 1, but only 17.3% had received enhanced referral. After phase 2, 61.9% received enhanced referral and 39.9% accessed EID, a significant 3-phase improvement (P = 0.007). In adjusted analysis, the likelihood of EID at any time was higher in the phase 2 group versus phase 0 (adjusted hazard ratio: 1.68, 95% confidence interval: 1.19 to 2.37, P = 0.003). CONCLUSIONS: Retention improved by 55% with a simple referral enhancement. Quality improvement efforts could help improve care in Mozambique and other low-resource countries [added].

Assessment of health literacy and numeracy among Spanish-Speaking parents of young children: validation of the Spanish Parental Health Literacy Activities Test (PHLAT Spanish).

OBJECTIVE: To assess the health literacy and numeracy skills of Spanish-speaking parents of young children and to validate a new Spanish language health literacy assessment for parents, the Spanish Parental Health Literacy Activities Test (PHLAT Spanish). METHODS: Cross-sectional study of Spanish-speaking caregivers of young children (<30 months) enrolled at primary care clinics in 4 academic medical centers. Caregivers were administered the 10-item PHLAT in addition to validated tests of health literacy (S-TOFHLA) and numeracy (WRAT-3 Arithmetic). Psychometric analysis was used to examine item characteristics of the PHLAT-10 Spanish, to assess its correlation with sociodemographics and performance on literacy/numeracy assessments, and to generate a shorter 8-item scale (PHLAT-8). RESULTS: Of 176 caregivers, 77% had adequate health literacy (S-TOFHLA), whereas only 0.6% had 9th grade or greater numeracy skills. Mean PHLAT-10 score was 41.6% (SD 21.1). Fewer than one-half (45.5%) were able to read a liquid antibiotic prescription label and demonstrate how much medication to administer within an oral syringe. Less than one-third (31.8%) were able to interpret a food label to determine whether it met WIC (Special supplemental nutrition program for Women, Infants, and Children) guidelines. Greater PHLAT-10 score was associated with greater years of education (r = 0.49), S-TOFHLA (r = 0.53), and WRAT-3 (r = 0.55) scores (P < .001). Internal reliability was good (Kuder-Richardson coefficient of reliability; KR-20 = 0.61). An 8-item scale was highly correlated with the full 10-item scale (r = 0.97, P < .001), with comparable internal reliability (KR-20 = 0.64). CONCLUSIONS: Many Spanish-speaking parents have difficulty performing health-related literacy and numeracy tasks. The Spanish PHLAT demonstrates good psychometric characteristics and may be useful for identifying parents who would benefit from receiving low-literacy child health information.