A conceptual model of functional health literacy to improve chronic airway disease outcomes.

BACKGROUND: Current conceptual models of health literacy (HL) illustrate the link between HL and health outcomes. However, these models fail to recognize and integrate certain elements of disease management, health system factors, and socio-demographic factors into their framework. This article outlines the development of Chronic Airway Disease (CAD) Management and Health Literacy (CADMaHL) conceptual model that integrates the aforementioned elements and factors into a single framework. METHODS: Information obtained during the following stages informed the development of our model: (1) a systematic review of existing CAD HL measurement tools that apply core HL domains; (2) patient-oriented focus group sessions to understand HL barriers to CAD self-management practices; (3) key-informant interviews to obtain potential strategies to mitigate CAD management barriers, and validate disease self-management topics; (4) elicited the perspectives of Canadian respirologist's on the ideal functional HL skills for asthma and COPD patients. RESULTS: Throughout the study process many stakeholders (i.e., patients, key-informants, and an international HL advisory panel) contributed to and reviewed the model. The process enabled us to organize the CADMaHL model into 6 primary modules, including: INPUT, consisting of four HL core components (access, understand, communicate, evaluate,) and numeracy skills; OUTPUT, including application of the obtained information; OUTCOME, covering patient empowerment in performing self-management practices by applying HL skills; ASSESSMENT, consisting of information about functionality and relevancy of CADMaHL; IMPACT, including mediators between HL and health outcomes; CROSSCUTTING FACTORS, consisting of diverse socio-demographics and health-system factors with applicability across the HL domains. CONCLUSIONS: We developed the CADMaHL model, with input from key-stakeholders, which addresses a knowledge gap by integrating various disease management, health-system and socio-demographic factors absent from previous published frameworks. We anticipate that our model will serve as the backbone for the development of a comprehensive HL measurement tool, which may be utilized for future HL interventions for CAD patients. TRIAL REGISTRATION: NCT01474928 - Date of registration: 11/26/2017.

A pilot randomized controlled trial on the impact of text messaging check-ins and a web-based asthma action plan versus a written action plan on asthma exacerbations.

OBJECTIVE: We compared electronic asthma action plans (eAAP) supported by automated text messaging service (SMS) with written asthma action plans (AAP) on assessing acceptability and asthma control improvement. We hypothesized that the patients in eAAP group would have more improvements in their quality of life, asthma control and decreased asthma exacerbations. METHODS: Patients with physician-diagnosed asthma having at least one asthma exacerbation in the previous 12 months were recruited. Participants received individualized action plans and were randomly assigned into either the intervention (eAAP) or control (AAP) group. Intervention participants received weekly SMS, triggering assessment of asthma control and viewing their eAAP. We assessed applicability of Telehealth platform on asthma exacerbations, asthma control, and quality of life over a 12-month period. RESULTS: 106 patients were enrolled (eAAP = 52, AAP = 54). The cumulative response rate to all weekly SMS check-ins was 68.4%. Overall, 28% of patients checked into their eAAP during the intervention period. There were fewer exacerbations in the eAAP group (18%) compared to the AAP group (RR = 0.82 [95%CI 0.49, 1.36]), (P = 0.44). The mean scores for asthma control and quality of life were higher in the eAAP group compared to the AAP group by 4% (RR = 1.04 [95%CI 0.83, 1.30]), (P = 0.73) and 5.5% (RR = 1.06 [95%CI 0.87, 1.28]), (P = 0.59), respectively, but were not statistically significant. CONCLUSIONS: We demonstrated that the eAAP presented improved asthma control outcomes, but as expected the sample size was inadequate to show a significant difference, but based on this pilot study we plan a larger appropriately powered randomized controlled trial (RCT).

The importance of informational, clinical and personal support in patient experience with total knee replacement: a qualitative investigation.

BACKGROUND: Total knee arthroplasty (TKA) is the most frequently performed joint replacement surgery in North America. Patient perspectives on TKA have been investigated in various ways, including finding as many as 20% of TKA patients are dissatisfied with their surgical outcomes. Understanding the patient experience with TKA broadly and in relation to patient satisfaction is a key gap in existing literature. METHODS: We report on the qualitative component of a mixed methods prospective cohort study examining patient experience and satisfaction post-TKA for adults in British Columbia, Canada. Data collection consisted of 45 in-depth interviews about individuals' knee surgery experiences conducted eight months after surgery. Analysis consisted of thematic coding by multiple coders. RESULTS: Participants' descriptions of their TKA experiences were primarily concerned with support, or the provision of aid and assistance. Support was insufficient when their expectations of support were not met; unmet support expectations led to an overall negative TKA experience. Support operated in three key domains: (1) informational support, (2) clinical support, and (3) personal support. Key sources of informational and clinical support included pre-optimisation clinics, surgeons, and physiotherapists. Key topics for informational support included pain, pain management, and recovery trajectories. Personal support was provided by family, friends, other TKA patients, employers, and themselves. CONCLUSIONS: Patient needs and expectations for support are shaped both before and after TKA surgery. Patients with an overall positive TKA experience had improvement in their knee pain, stiffness or functioning post-TKA, had their major expectations and needs for support met during their TKA recovery, and believed that any significant future expectations or needs for ongoing support would be adequately met. In contrast, patients with an overall negative TKA experience had at least one major expectation or need for support not met during their TKA recovery, even in cases where they had good TKA outcomes. Suggested interventions to improve the experience of persons receiving TKA include an expanded patient navigator model, revised pre-surgery educational materials, particularly around pain expectations and management, and comprehensive sharing of other patients' TKA experience.

Evaluation of a New Performance-Based Health Literacy Measurement Tool for Individuals With Chronic Airways Disease.

BACKGROUND: Low health literacy is a global challenge. Health literacy is positively correlated with chronic airways disease desirable outcomes. Despite the importance of health literacy in disease management, current health literacy measurement tools are suboptimal. As part of a multi-stage project to develop a performance-based, disease-specific Vancouver Airways Health Literacy Tool (VAHLT) for individuals with chronic airways disease, this study assessed the relationships between the VAHLT scores and characteristics of patients with chronic airways disease. The primary aim of the study was to provide preliminary evidence of construct validity of the VAHLT. METHODS: A cross-sectional study design was applied. Study subjects were recruited from 6 specialty care clinics to complete the VAHLT measurement tool. Demographic and clinical data, including quality of life and disease control, were collected via validated questionnaires. The study subjects also completed a spirometry test. Inferential analysis was conducted by using mean difference testing and correlational methods. RESULTS: A total of 320 subjects were recruited, and, after imputing missing data, 315 were ultimately analyzed. The subjects were predominantly women (61%), white (83%), had a post-high-school education (74%), and a mean ± SD age of 65.2 ± 13.2 y. Age was significantly negatively correlated with the VAHLT scores (P = .004); the subjects with a post-high school education had significantly higher VAHLT scores than those with a high school education or less (P < .001). No significant sex or ethnicity related differences in VAHLT scores were observed. For clinical outcomes, no significant differences were found between the VAHLT scores and disease severity or measures of quality of life and asthma control. CONCLUSIONS: We report a chronic airways disease-specific health literacy measurement tool developed with the involvement of patients and professionals. Age and education were highly correlated with health literacy, which emphasizes the importance of addressing these factors in health literacy interventions among patients with chronic airways disease.

A risk perception model to promote smoking cessation among adult current smokers: Application of a community-based smoking cessation intervention.

INTRODUCTION: This study aims to assess the changes in cigarette consumption CO levels, and importance and self-confidence levels of quitting smoking in adult smokers after participation in a 6-month community-based smoking cessation program. METHODS: Participants were enrolled in the intervention (counseling group) or noncounseling group after completing a baseline assessment and receiving educational materials. A final assessment was completed at 6 months and at 8 months. Mixed factorial analyses of variance (ANOVAs) with 2 (condition: counseling vs non-counseling) × 2 (spoken language: Chinese vs English) × 2 (time: initial measurement vs last measurement) designs, were conducted for each of the four outcome measures. RESULTS: Seventy smokers (50 males, 20 females; mean age 34 years, SD=9.68) from the Mandarin- and Cantonese-speaking (n=30) and English-speaking (n=40) communities in Vancouver, Canada were enrolled. Cigarette consumption: Both Chinese- and English-speaking participants significantly decreased their cigarette consumption at near equal rates and English-speaking participants smoked significantly more cigarettes than the Chinese-speaking participants did across both the initial and last measurement time points. No significant interactions or main effects related to the study condition variable were observed. CO levels: Average levels of CO also decreased near equally for the English- and Chinese-speaking groups. No significant interactions or main effects related to the study condition variable were observed. Importance ratings: Chinese-speakers in the non-counseling group showed no increase in importance ratings, whereas Chinese-speakers in the counseling group saw an average increase of 0.73 (SD=1.10). For the English-speaking group, importance ratings remained stable over time with no significant changes. Self-confidence ratings: A larger average rating increase for the counseling group compared to the non-counseling group was observed for the study condition and time variables. On average, confidence ratings increased significantly for the whole sample. CONCLUSIONS: Our study showed that participation in a community-based smoking cessation intervention study, regardless of study group, resulted in significant decreases over time in self-reported cigarettes smoked per day and measured CO levels; as well as a significant effect on importance ratings depending on the language group, and a significant increase in confidence ratings overall.

Exploring chronic airways disease patients' perspectives on self-management topics.

OBJECTIVES: In this study, we explored chronic airways disease (CAD) patients' responses to health literacy (HL) communication domain questions within disease self-management scenarios, as part of a larger CAD HL measurement tool development study. METHODS: Adult asthma and chronic obstructive pulmonary disease (COPD) patients from specialty care respiratory clinics were initially presented with realistic disease management scenarios and asked to share information they would communicate. Participants' responses were grouped into response categories that were reviewed and verified by key informants. A new cohort of CAD patients then responded to the same scenarios and had their answers placed into the developed response categories by trained interviewers. RESULTS: 19 initial stage participants' responses informed response categories for the following self-management topics: Inhaler Use (n = 20); Prednisone Use (n = 30); Flu (Influenza) (n = 35); and Weather Forecasting & Air Quality Index (n = 29). 141 participants' responses were categorised during the second stage. CONCLUSIONS: Specialty care CAD patients displayed an understanding of key information to communicate across disease self-management topic. Our two-step, patient-driven approach may interest researchers investigating health-related communication from patients' perspectives. PRACTICE IMPLICATIONS: Findings may illuminate potential areas to investigate communication gaps among CAD patients; further investigation is warranted among non-specialty care patients.

An Integrated Framework to Conceptualize and Develop the Vancouver Airways Health Literacy Tool (VAHLT).

There is currently no comprehensive tool to assess the functional health literacy (HL) skills of chronic airway disease (CAD) patients. The purpose of this article is to describe the development of a new HL measure, the Vancouver Airways Health Literacy Tool (VAHLT). The tool was developed through the following phases: (1) Tool conceptualization, consisting of: (A) a systematic review (SR), (B) focus group sessions with CAD patients to understand barriers and facilitators to CAD management, (C) a survey with key-informants to obtain strategies to mitigate self-management barriers and validate patient-derived topics, and (D) respiratory physicians' review of the topics; (2) Scenario and item development; and (3) Tool testing and content validation. The SR identified the lack of a valid HL measurement tool for CAD patients. Patients provided an initial shortlist of disease-related self-care topics. Key-informants helped to finalize topics for inclusion. Respiratory physicians and patients contributed to the development of a scenario-based questionnaire, which was refined during three rounds of testing to develop a 44-item instrument comprising nine self-management passages. We highlight the holistic process of integrating information from the literature with knowledge gained from key stakeholders into our tool framework. Our approach to stakeholder engagement may be of interest to researchers developing similar tools, and could facilitate the development and testing of HL-based interventions to ultimately improve patient outcomes and reduce the burden on the healthcare system.

Factors Affecting Health Literacy as Related to Asthma and COPD Management: Learning from Patient and Health Care Professional Viewpoints.

BACKGROUND: Studies have identified health literacy (HL) as an important determinant of asthma and chronic obstructive pulmonary disease (COPD) management. There are, however, limited data on patients' and health care professionals (HCPs') insights about the link between HL and management of asthma and COPD. OBJECTIVE: The aim of this study was to elicit patients' and HCPs' perspectives with respect to factors affecting HL in the context of asthma and COPD management. METHODS: A total of 16 semi-structured focus groups (10 in English and 6 in French) with patients with asthma or COPD (n = 93) and 45 interviews with HCPs, researchers, and policymakers were conducted between June 2015 and April 2017. Participants were asked to share their perspectives with respect to five predefined HL domains-accessing, understanding, evaluating, communicating, and using health-related information-in relation to disease self-management practices. Data were analyzed qualitatively, using a content analysis approach. KEY RESULTS: Most patients and HCPs reflected on factors hampering HL in relation to asthma and COPD management. Thoughts such as "not having enough time during medical consultations," "not receiving consistent messages from different health care professionals," and "language or cultural differences" were frequently mentioned by both patients and HCPs. CONCLUSIONS: We identified multiple factors affecting communication between patients and HCPs as it relates to the self-management of their disease. These included inconsistent messages from different providers, limited consultation time, use of technical language, failure to account for cultural differences, and reduced health literacy, especially as it related to written communication. Future interventions that aim to enhance HL skills in the context of asthma and COPD self-management should consider these issues. [HLRP: Health Literacy Research and Practice. 2021;5(3):e179-e193.] Plain Language Summary: The current study advances the health literacy (HL) knowledge base by adding patients' and health care professionals' valuable insights on factors that hamper or facilitate HL in relation to asthma and chronic obstructive pulmonary disease (COPD) management. An important insight from this study is that receiving conflicting information from different health care professional's hampers HL in patients with asthma and/or COPD.

Chinese- and English-speaking adult current smokers' perspectives on smoking and culturally and linguistically appropriate cessation: a qualitative analysis.

BACKGROUND: A lack of culturally and linguistically appropriate smoking cessation intervention programs exist among Chinese-Canadian communities. Smoking cessation programs that are provided in Canadian mainstream culture and language have shown limited effectiveness in altering smoking behaviours of smokers from these communities. Our study aimed to explore and compare smoking patterns, knowledge, beliefs, and risk perceptions of adult current smokers between Chinese- and English-speaking Canadians participating in a culturally and linguistically tailored smoking cessation program. METHODS AND DESIGN: A qualitative study embedded in an effectiveness study using an 8-month quasi-experimental design, was conducted to compare the effects of four one-on-one culturally and linguistically sensitive consultation sessions (intervention group) and three telephone follow-up assessments (control group). All participants were provided take-home educational materials (designed exclusively for this study), and completed study questionnaires at baseline and 6-month post-intervention. An 8-month post-intervention phone assessment was conducted with all participants to assess cessation progress and maintenance. PARTICIPANTS: 70 Chinese- and English-speaking adult (aged 19-80) current smokers (≥ 5 cigarettes per day) residing in the Greater Vancouver Area, Canada, were recruited between May 2018 and April 2019. DATA ANALYSIS: Thematic analysis was conducted on self-reported qualitative information from study questionnaires and verbatim transcripts of in-person consultations and telephone follow-ups. Cultural- and demographic-related themes were considered. RESULTS: Perceptions of smoking patterns, smoking status, triggers, and barriers to smoking cessation were identified. Important elements of smoking cessation program, including facilitator characteristics, duration, procedures, cultural factors, and topics were also identified. Differences in perceptions of smoking were observed between gender and language groups. Stress was a major trigger for smoking in both language groups. An individual's social network was reported as the largest barrier to successful cessation for Chinese-speaking participants. CONCLUSIONS: Our study provides knowledge and information to further examine the role of risk perception (realization of the possible harms of smoking) in smoking cessation to facilitate the development of future interventions that could more effectively promote smoking cessation among new immigrants and within ethnocultural communities. We found that our program was generally accepted by smokers in both language groups and the participants reported that they were able to apply the strategies learned in the intervention during their quit smoking plan.

Assessing factors influencing smoking and smoking cessation within Chinese communities in the Greater Vancouver Area: A qualitative exploratory study.

INTRODUCTION: The prevalence of smoking is high within Chinese-Canadian communities and there is a lack of culturally and linguistically appropriate smoking cessation resources and services. We aimed to ascertain factors affecting smoking and smoking cessation from the perspectives of current smokers and key informants. METHODS: As part of a multistage mixed-methods study taking place from January 2013 to June 2014, a qualitative exploratory study design was conducted applying a community-based participatory research approach. Focus groups and interviews were conducted with adult (aged ≥19 years) Chinese-Canadian current smokers (≥5 cigarettes per day for the past 30 days) and interviews were held with key informants in Vancouver, Canada. A constant comparison method was applied to code data, and an inductive approach was used to identify emergent themes. RESULTS: In all, 35 smokers from the target communities (11 female, 24 male) participated in 4 focus group sessions and 17 key informants (14 female, 3 male) were individually interviewed. Internal and external factors influencing smoking onset, continuation, and cessation from the perspectives of smokers and key informants were identified. Male smokers thought that the most influential factor influencing smoking initiation was social pressure, while female smokers thought that it was stress. Female smokers reported refraining from seeking cessation assistance due to a perceived negative image of female smokers within the community. Both key informants and participants indicated that involving friends and family in the quitting process may help to motivate smokers. CONCLUSIONS: Smokers from Chinese-Canadian communities may benefit from linguistically appropriate and culturally relevant smoking cessation interventions that consider prevailing attitudes, perceptions, and beliefs. The knowledge gained may inform the development of future smoking cessation programs and resources for the target community, while our approach may be applicable to other ethnocultural or immigrant communities.

Development and Pretesting of a New Functional-Based Health Literacy Measurement Tool for Chronic Obstructive Pulmonary Disease (COPD) and Asthma Management.

Background: Health literacy (HL) is a person's ability to practically apply a wide range of cognitive and non-cognitive skills in health-related decisions. HL includes five domains: navigate/access, understand, communicate, evaluate, and use of health information and services. Currently, no tool accurately captures and measures HL in adult patients with asthma and COPD, while utilizing all 5-HL domains. Objective: Develop a comprehensive functional-based measurement tool for adult asthma and/or COPD patients, while assessing HL on routine actions required to manage their chronic respiratory condition(s). Methods: We developed our HL tool based on a conceptualization of the link between HL and asthma and COPD management, during needs assessment stage including; a systematic review, which was followed by patient-oriented focus groups, and key-informant and respirologist interviews. Preliminary face and content validation were obtained by patients' and health professionals' input prior to the pretesting stage. The needs assessment information enabled us to develop passages in scenario-format and corresponding items to assess HL core domains, in addition to numeracy skills, across nine self-management topics: peak flow meters, prednisone use, pulmonary rehabilitation, action plans, flu shots, inhaler technique, lifestyle (nutrition and exercise), trigger control, and map navigation. The tool was pretested with asthma and COPD patients to assess its relevance, clarity, and difficulty. Results: Our systematic review identified the deficiencies of existing HL tools that assessed the HL skills of asthma and COPD patients. The patient-oriented focus groups (n=93) enabled us to identify self-management topics and develop items for our proposed HL tool, which were enriched by input from 45 key informants (eg, policy makers, clinicians, etc.) and 17 respiratory physicians. Preliminary pretesting with a new cohort of participants (36 asthma and COPD patients and 39 key informants) aided in the refinement and finalized our tool. The modified tool included passages and corresponding items related to asthma and COPD management was pretested with 75 asthma/COPD patients who completed the questionnaire and provided their feedback on the clarity, relevance, and difficulty of the tool. The main barrier to self-management pertained to "communication" skills. The flu shot was the most relevant topic (91.2%), while map navigation was the least relevant (63.9%). Action plans were the most difficult topic, where only 55% knew when to utilize their action plans. Numeracy items challenged COPD patients the most. Conclusion: We summarized findings from the development and preliminary testing stages of a new asthma/COPD HL tool. This tool will now be validated with a new cohort of patients. Practice Implications: Knowledge gained in this study has been applied to the final version of the tool, which is currently being validated.

Asthma and COPD patients' perceived link between health literacy core domains and self-management of their condition.

OBJECTIVE: Health literacy (HL) is a person's ability to practically apply a wide range of cognitive and non-cognitive skills, to make health-related decisions. Currently, no tool applies all HL core domains to capture necessary data to measures HL in adult asthma and COPD patients. We endeavored to develop a comprehensive, function-based tool that adequately and accurately measures HL skills of this patient population. We explored the perspectives of patients related to each core HL domain, with an emphasis on self-management practices. METHODS: Sixteen focus groups were conducted (n = 93; 40 asthma and 53 COPD) across Canada. Data was analyzed using NVivo12. RESULTS: Thirteen subthemes were identified within five HL domains: (a) access: active access; passive access; lack of access; (b) understanding: how to improve understanding; (c) trustworthiness; relevancy and validity of information: pre- and post- application of information; (d) communication: barriers to proper communication; (e) application of information: making health decisions. CONCLUSIONS: Participants provided valuable insight in terms of disease management topics and corresponding items to include in our HL tool. PRACTICE IMPLICATIONS: Involvement of patients from initial stage allowed us to develop a tool that will serve as a first ever developed HL tool for asthma and COPD patient group.

Health literacy in chronic disease management: a matter of interaction.

Health literacy plays a crucial role in chronic disease management. To comprehensively manage chronic conditions on a daily basis, individuals must be able to assess, understand, evaluate, and use health information. Several key publications emphasize that health literacy is not merely a matter of individual skills but that it is highly dependent on the accessibility of health-care systems, the communication skills of health-care professionals, and the level of complexity of the health information. However, the literature indicates that health literacy is mainly framed and measured as an individual attribute in research. Focusing health literacy research solely on the individual, rather than also including the health-care context, limits our understanding of the type of actions that should be undertaken to facilitate a person's access to and understanding, evaluation and use of health information. This commentary highlights the importance of interpreting the concept of health literacy as a dynamic construct that emerges from the interaction between patients/citizens and health-care systems, organizations, and professionals. This approach has the potential to fill a gap in our understanding of the link between health literacy and chronic disease management. Such an understanding would facilitate the development of comprehensive health literacy measurement instruments and interventions to enhance health literacy.

Airway diseases and health literacy (HL) measurement tools: A systematic review to inform respiratory research and practice.

OBJECTIVE: To identify and evaluate asthma/COPD measurement tools that assess any of the five health literacy (HL) domains: (1) access, (2) understand, (3) evaluate, (4) communicate, and (5) use, as well as numeracy. METHODS: MEDLINE/Embase (via Ovid) databases from 1974 to 2016 were searched and complimented by grey literature. Study selection and data extraction were conducted by two reviewers independently. RESULTS: We identified 65 tools including 40 asthma, 22 COPD, and 3 asthma/COPD focused tools. Thirty tools had been validated and two assessed all five domains. The 'understand' domain was captured in 49 tools, followed by 'access' in 29 tools, 'use' in 24 tools, 'evaluate' in 20 tools, and 'communicate' in 10 tools. Two tools assessed 'numeracy'. Tool content comprised disease physiology, triggers, symptoms, inhaler technique, self-management practices, and rehab programs. CONCLUSIONS: This review highlights paucity of HL tools that have been validated and/or assess the 'communicate' domain and makes a valuable contribution to filling an existing research gap in the field of HL by determining the deficiencies of such tools. PRACTICE IMPLICATIONS: Our review uncovers which HL domains are under-measured, justifying the need to develop an airways HL measurement tool which applies the 5-domain model for asthma/COPD management.

Using Exploratory Focus Groups to Inform the Development of a Peer-Supported Pulmonary Rehabilitation Program: DIRECTIONS FOR FURTHER RESEARCH.

PURPOSE: There has been limited research on the role of peer support in self-management for patients with chronic obstructive pulmonary disease (COPD) attending pulmonary rehabilitation (PR) programs. This research explored patient acceptability of "peer supporters" in promoting sustained self-management practices after PR and to assess their perceived self-efficacy to manage their disease. METHODS: This qualitative study used focus groups and individual interviews to identify perspectives of peer supporters and benefits of participation in a PR program. The analysis included systematically reading and reviewing transcripts of the sessions, establishing themes, and sorting responses into thematic categories. RESULTS: A total of 28 patients with COPD (15 males) participated in either a focus group or interview. The majority of participants considered peer supporters to be good facilitators for motivating ongoing exercise after completing PR. Exercise sessions were viewed as extremely beneficial for disease management, and many were satisfied with the care they had received. Most subjects wanted to receive followup sessions with either a professional or peer after the intensive phase of PR. Overall, the concept of having a peer supporter involved in ongoing maintenance of self-management efforts after PR was generally viewed as positive. CONCLUSIONS: Integrating a peer support model into PR programs may improve better long-term health outcomes for COPD management as many participants endorsed the need for continued support after the program. It also improved our understanding of the role of "peer supports" in exercise and self-care maintenance after PR. The selection of peers and the specific model used warrants further investigation in a randomized controlled trial.

Culturally Specific Evaluation of Inhaler Techniques in Asthma.

BACKGROUND: Little work has been done on identifying the impact of educational materials developed by immigrant patients themselves, along with their caregivers and health professionals in terms of inhaler use technique. The purpose of this study was to evaluate understanding of physicians' instructions on asthma management and inhaler techniques in Punjabi and Chinese subjects using educational interventions in their native languages. METHODS: Eighty-seven subjects with asthma were randomly assigned to either one of 3 experimental groups (physician-led video, subject-generated community video, or both) or a control group (educational pamphlet). Medication knowledge and inhaler skills were measured during 3 in-person interviews. RESULTS: Subjects in all 3 experimental groups, when compared with control subjects, demonstrated improvements in the follow-up test in terms of ability to use inhalers correctly (P < .001) and understanding of physicians' instructions (P = .008). Chinese participants showed significantly greater improvements compared with Punjabi participants for the correct use of inhalers (P < .047), and females showed greater improvements compared with male subjects (P = .04). CONCLUSIONS: The educational interventions developed were successful in behavioral modification and beneficial beyond usual care in terms of improving proper use of inhalers and understanding of physicians' instructions. The findings can be translated to health education practice, promoting the development of short, simple, and culturally linguistically appropriate learning materials for patients. Such interventions that draw on patients' life experiences and socio-cultural context can overcome certain limitations of conventional patient education approaches. (ClinicalTrials.gov registration NCT01474928.).

The application of health literacy measurement tools (collective or individual domains) in assessing chronic disease management: a systematic review protocol.

BACKGROUND: The term "health literacy" (HL) was first coined in 1974, and its most common definition is currently defined as a person's ability to access, understand, evaluate, communicate, and use health information to make decisions for one's health. The previous systematic reviews assessing the effect of existing HL measurement tools on health outcomes have simply searched for the term "health literacy" only to identify measures instead of incorporating either one or more of the five domains in their search. Furthermore, as the domain "use" is fairly new, few studies have actually assessed this domain. In this protocol, we propose to identify and assess HL measures that applied the mentioned five domains either collectively or individually in assessing chronic disease management, in particular for asthma and chronic obstructive pulmonary disease (COPD). The ultimate goal is to provide recommendations towards the development and validation of a patient-centric HL measurement tool for the two diseases. METHODS/DESIGN: A comprehensive, electronic search will be conducted to identify potential studies dating from 1974 to 2016 from databases such as Embase, MEDLINE, CINAHL, Cochrane Central Register of Controlled Trials, Web of Science, ERIC, PsycINFO, and HAPI. Database searches will be complemented with grey literature. Two independent reviewers will perform tool selection, study selection, data extraction, and quality assessment using pre-designed study forms. Any disagreement will be resolved through discussion or a third reviewer. Only studies that have developed or validated HL measurement tools (including one or more of the five domains mentioned above) among asthma and COPD patients will be included. Information collected from the studies will include instrument details such as versions, purpose, underlying constructs, administration, mapping of items onto the five domains, internal structure, scoring, response processes, standard error of measurement (SEM), correlation with other variables, clinically important difference, and item response theory (IRT)-based analyses. The identified strengths and weaknesses as well as reliability, validity, responsiveness, and interpretability of the tools from the validation studies will also be assessed using the COSMIN checklist. A synthesis will be presented for all tools in relation to asthma and COPD management. DISCUSSION: This systematic review will be one of several key contributions central to a global evidence-based strategy funded by the Canadian Institutes of Health Research (CIHR) for measuring HL in patients with asthma and COPD, highlighting the gaps and inconsistencies of domains between existing tools. The knowledge generated from this review will provide the team information on (1) the five-domain model and cross domains, (2) underlying constructs, (3) tool length, (4) time for completion, (5) reading level, and (6) format for development of the proposed tool. Other aspects of the published validation studies such as reliability coefficients, SEM, correlations with other variables, clinically important difference, and IRT-based analyses will be important for comparison purposes when testing, interpreting, and validating the developed tool. SYSTEMATIC REVIEW REGISTRATION: PROSPERO CRD42016037532.

Nutritional interventions for Alzheimer's prevention: a clinical precision medicine approach.

Alzheimer's disease (AD) is a major source of morbidity and mortality, with the disease burden expected to rise as the population ages. No disease-modifying agent is currently available, but recent research suggests that nutritional and lifestyle modifications can delay or prevent the onset of AD. However, preventive nutritional interventions are not universally applicable and depend on the clinical profile of the individual patient. This article reviews existing nutritional modalities for AD prevention that act through improvement of insulin resistance, correction of dyslipidemia, and reduction of oxidative stress, and discusses how they may be modified on the basis of individual biomarkers, genetics, and behavior. In addition, we report preliminary results of clinical application of these personalized interventions at the first AD prevention clinic in the United States. The use of these personalized interventions represents an important application of precision medicine techniques for the prevention of AD that can be adopted by clinicians across disciplines.

Assessing beliefs and risk perceptions on smoking and smoking cessation in immigrant Chinese adult smokers residing in Vancouver, Canada: a cross-sectional study.

OBJECTIVES: We aimed to conduct culturally-based participatory research to assess cultural and belief contexts for smoking behaviours within Mandarin and Cantonese communities. Outcome variables were smoking-related knowledge, smoking patterns, attitudes and beliefs, and perceived barriers and facilitators to successful cessation. DESIGN: A community-based approach was applied involving smokers, community key-informants and professionals in study design and implementation. Initially, focus groups were conducted and findings were used to develop study instrument. Participants responded once to study questionnaire after informed consent. SETTING: Community based in the Greater Vancouver Area, Canada. PARTICIPANTS: 16 Chinese smokers participated in focus groups and subsequently, 167 current Chinese immigrant (137 males and 30 females) smokers from Mandarin and Cantonese communities, recruited with the help of community agencies and collaborating physicians, were enrolled in a cross-sectional study. RESULTS: We found that a majority believed smoking was harmful on their health. Younger smokers (<35 years of age) did not mind smoking in front of young children compared to older smokers (≥35 years of age) (p<0.001). People with high school or lower levels of education believed that they would benefit more from smoking than suffering from withdrawal symptoms compared to better educated smokers (p<0.05). Mandarin smokers were significantly more likely to encourage others to quit than Cantonese smokers (p<0.05). Many indicated not receiving adequate support from care providers and lack of access to culturally and linguistically appropriate cessation programmes impacted on their ability to quit smoking. CONCLUSIONS: Our study highlighted the importance of tobacco beliefs and perceptions among Mandarin and Cantonese speaking immigrants with limited access to healthcare information and for younger smokers whose attention to health consequences of smoking may be limited as well. Study participants were generally aware of the health risks and were willing to quit. Access to appropriate cessation programmes would fulfil their willingness.

Does culture or illness change a smoker's perspective on cessation?

OBJECTIVES: To explore cultural context for smoking cessation within Chinese communities in Vancouver, and identify opportunities to support development of culturally appropriate resources for cessation. METHODS: Applied participatory approach involving community members, patients, and key-informants in the design and implementation of the research. RESULTS: Whereas many participants were motivated to quit, their perceptions of desire to do so were not supported by effective interventions and many attempts to quit were unsuccessful. CONCLUSION: Tobacco control clinics and care providers need to adopt culturally and linguistically relevant interventions to facilitate behavioral modifications and cessation in ethnic minority communities.