Health literacy competency requirements for health professionals: a Delphi consensus study in Taiwan.

BACKGROUND: Cumulative evidence supports the importance of health literacy in determining the quality of healthcare delivery and outcomes. To enhance health literacy competencies among professionals and alleviate healthcare barriers owing to patients' inadequate health literacy, evidence-based health literacy competency guidelines are needed for the development of health professionals' training curricula. The aim of this study was to validate and refine a set of health literacy competencies, including knowledge, attitude, and skills of health professionals, and to prioritize the importance of health literacy practices among healthcare professionals. METHODS: We employed a consensus-building approach that utilized a modified three-round Delphi process conducted in 2017. An online Delphi panel was assembled, comprising 20 Taiwanese health literacy experts from diverse fields such as medicine, nursing, public health, language, and communication. A set of health literacy competencies previously identified and validated by an international panel of health literacy experts was cross-culturally translated. RESULTS: After three rounds of ratings and modifications, a consensus agreement was reached on 42 of 62 health literacy competencies, including 12 of 24 knowledge items, 9 of 11 attitude items, and 21 of 27 skill items. Of the 32 health literacy practices, "avoidance using medical jargon," "speaking slowly and clearly with patients," and "using analogies and examples" were deemed most important by the panelists. CONCLUSIONS: The Delphi panel's consensus helped to identify a set of core health literacy competencies that could serve as measurable learning objectives to guide the development of a health literacy curriculum for health professionals. The prioritized health literacy practices can be employed as indicators of health literacy competencies that health professionals should learn and routinely use in clinical settings.

Sleep and its association with dental caries or myopia in first graders.

AIM: First grade is a transition from pre-school to school-age. The change in lifestyle behaviours such as sleep may have a physiological response, which contributes to the presence or absence of two highly incident diseases: dental caries or myopia. The aim of the study was to examine the association between sleep and myopia as well as sleep and dental caries in first graders. DESIGN: It is a cross-sectional study. METHODS: This was a recruitment phase of an interventional study. A total of 338 children whose caregivers completed a Children's Sleep Habits Questionnaire. Caregivers also provided information regarding myopia and caries status of children and their parents. Binary logistic regression was applied to analyse the potential risk factors. RESULTS: Dental caries and myopia rates were 45.9% and 9.5%, respectively. After adjusting for children's gender, children's age, fathers with caries and mothers with caries, the odds ratio for dental caries in children who slept less than 9 h when compared to those who slept for nine and more hours was 1.94. Mothers with caries were 3.37 times more likely to have children with caries than mothers without caries. However, sleep was not associated with myopia in first graders. CONCLUSION: Sleeping less than 9 h and maternal caries were risk factors of children developing dental caries. Future sleep and myopia studies can be conducted on higher graders who may present prolonged exposure and accumulations of myopic risk factors. IMPLICATIONS: Screening of children with insufficient sleep is needed for nurses to enable the early identification of high-risk groups for dental caries in school settings. Family nurses are encouraged to work with family members to implement tailored sleep interventions, in order to facilitate better sleep and oral health practices in both school and home settings. REGISTRATION: This study protocol was registered on ClinicalTrials.gov (Registration number: Redacted).

Development and Psychometric Evaluation of the Place Attachment for Community-Dwelling Older Adults Scale.

This study developed the Place Attachment for Community-Dwelling Older Adults (PACOA) scale and evaluated its psychometric properties. The PACOA was developed through a qualitative study and expert panels. A pilot study confirmed the 19-item PACOA which included five factors (meaning of life, dependency, feeling "in place," continuity, and social inclusion) were extracted. This model explained 60.803% of the variance. Cronbach's α of the PACOA and its subscales were .853 and .670 to .863, respectively, whereas the correlations between the PACOA and its subscales were .580 to .725 (p < .01). The criterion validity and test-retest reliability were .678 (p < .01) and r = .654 (p < .01). Our findings suggest that the PACOA is an indicator of the emotional connection between older adults and their places of residence. Future studies should address the older adult-place fit, the future connection characteristics, and the influence of place attachment on older adults' healthy lifestyle behaviors.

Effect of a community-based participatory health literacy program on health behaviors and health empowerment among community-dwelling older adults: A quasi-experimental study.

This study evaluated the effect of a community-based participatory health literacy program aimed at improving the health behaviors and health empowerment for older adults. A two-group pretest and posttest quasi-experimental design with surveys conducted at baseline (T1), immediately after the intervention (T2), and 6 months after the intervention (T3). The intervention group (n = 94) attended a 12-week health literacy program; while the comparison group (n = 78) did not. The results demonstrated that intervention group had significantly better health behavior practices for weight control (OR = 3.71, 95% CI = 1.59-8.64), regular exercise (OR = 15.26, 95% CI = 1.92-121.13), and health information navigation (OR = 2.61, 95% CI = 1.16-5.84). Health empowerment was significantly higher in the intervention group than the comparison group (p < 0.01).This study suggests that integrating community-based participatory design is effective in improving some health behaviors and health empowerment in older adults over a short period.

Is health literacy associated with greater medical care trust?

OBJECTIVE: To examine the relationship between health literacy and trust in physicians and in the healthcare system. DESIGN: A cross-sectional survey of a nationally representative sample of adults. SETTING: Taiwan. PARTICIPANTS: Non-institutionalized adults (N = 2199). MAIN MEASURES: Trust in physicians was a composite measure assessing respondents' general trust in physicians and their perceptions of their physician's communication, medical skills, beneficence, honesty, confidentiality, respect and fairness. Trust in the healthcare system was a single-item measure. Health literacy was measured by four items. RESULTS: Respondents with higher health literacy had, overall, higher levels of trust in physicians (P<0.001) and in the healthcare system (P = 0.04). Health literacy remained significantly and positively associated with trust in physicians (P<0.001) and in the healthcare system (P = 0.001) after adjusting for respondents' sociodemographic characteristics. CONCLUSIONS: Our findings demonstrate that health literacy is positively associated with trust. Actionable plans targeting health literacy at the national and local levels to establish a health literate care environment may contribute to enhancing trust in physicians and the healthcare system.

The Roles of Social Support and Health Literacy in Self-Management Among Patients With Chronic Kidney Disease.

AIMS: To investigate the relationships among social support, health literacy, and self-management, and the factors influencing self-management of chronic kidney disease (CKD). DESIGN: Cross-sectional study. METHODS: A random sample of 410 patients was recruited from nephrology clinics. Data were collected using structured questionnaires and chart reviews from January 2013 to February 2014. Hierarchical regression analysis was used to determine the predictive factors of self-management behaviors and ∆R2 to determine each variable's explanatory power. FINDINGS: Health literacy and social support were positively correlated with self-management behaviors. Furthermore, social support, health literacy, and marital status were significant predictors of self-management behaviors. Social support had a relatively greater explanatory power for self-management behaviors than did health literacy. Particularly, healthcare provider support had the greatest influence on patients' self-management behaviors. CONCLUSIONS: Health literacy and social support play independent positive roles in self-management behaviors of patients with CKD, with social support having a particularly dominant role. Further research using a systems approach to improving self-management behaviors is necessary to clarify the role of social support. CLINICAL RELEVANCE: Health literacy and social support are independently and positively related to self-management. Social support, which is a system-level factor, is a relatively stronger and crucial predictor than is health literacy. Nurses have to refine self-management programs to focus on families and adopt a systems approach to help CKD patients improve their self-management behaviors.

Impact of a Problem-Based Learning (PBL) Health Literacy Program on Immigrant Women's Health Literacy, Health Empowerment, Navigation Efficacy, and Health Care Utilization.

We evaluated the effectiveness of a problem-based learning (PBL) health literacy program aimed to improve health literacy, health empowerment, navigation efficacy, and health care utilization among immigrant women in Taiwan. We employed a quasi-experimental design that included surveys at the baseline, immediately after the intervention, and 6 months after the intervention. The intervention group participated in a 10-session PBL health literacy program and the comparison group did not. Results showed that 6 months after the intervention, the intervention group had significantly fewer ER visits and hospitalizations than the comparison group. The intervention group reported a greater decrease in delaying/avoiding health care due to communication barriers. Although the intervention group showed improvement in health literacy, health empowerment and navigation self-efficacy, the differences were not statistically significant. The PBL health literacy program resulted in fewer ER visits and hospitalizations, and better health care access among immigrant women. Cognitive and psychological outcomes examined in the study appeared more difficult to change. The PBL health literacy program effectively improved health care utilization and reduced barriers to health care access among immigrant women in Taiwan. It would be useful to examine the effectiveness of the program in other populations.

Development and validation of a Weight-Specific Health Literacy Instrument (WSHLI).

OBJECTIVE: Develop/validate a weight-specific health literacy instrument. METHODS: The development of weight-specific health literacy measurement consisted of seven phases: (a) a literature review; (b) consultation with weight management experts; (c) generation of an item pool; (d) selection of items via the Delphi method; (e) pilot testing; (f) a national survey; and (g) examination of the psychometric properties of the results. RESULTS: A random sample of 362 Taiwanese adults completed the face-toface survey. The results of factor analysis indicated reasonable good fit of a 2-factor model (χ2/df=1.1, p=0.18; RMSEA=0.02, CFI=0.99, TLI=0.99). Construct validity testing showed that the both factors were significantly correlated with s-MHLS (γ=0.71, p<0.001; γ=0.22, p<0.001), comprehension (γ=0.32, p<0.001: γ=0.10, p<0.05), and writing (γ=0.44, p<0.001: γ=0.11, p<0.05). Predictive validity testing showed that the first factor had significant correlations with weight management efficacy (γ=0.16, p<0.001), and three weight management behaviors. The second factor was significantly correlated with weight management efficacy (γ=0.11, p<0.05) but not with the 3 weight management behaviors. CONCLUSIONS: On the basis of the psychometric results, we conclude that the final version of Weight-Specific Health Literacy Instrument (WSHLI) includes the 13 items. It is a valid and reliable tool for weight management research and evaluation in Mandarin Chinese speaking populations.

Children's exposure to secondhand smoke at home before and after smoke-free legislation in Taiwan.

INTRODUCTION: In January 2009, Taiwan broadened smoke-free legislation, requiring mass transportation systems, indoor public areas and indoor workplaces with 3 or more people, to become smoke-free. We investigated the secondhand smoke (SHS) exposure at home for children aged 3-11 years in Taiwan before and after the implantation of the legislation. METHODS: We studied 7911 children from the 2005, 2009 and 2013 National Health Interview Surveys (cross-sectional, nationally representative household surveys). Logistic regression modelling estimated adjusted ORs (AOR) and 95% CIs for children's SHS exposure at home in 2009 and 2013 (2005 as reference) for the overall sample and for each category of household socioeconomic status (SES) and household composition. RESULTS: Prevalence of children SHS exposure at home decreased from 51% (2005) to 32% (2009) and 28% (2013). Compared to 2005, children in 2009 and 2013 had lower likelihoods of SHS exposure at home with AOR of 0.45 (95% CI 0.41 to 0.51) and 0.41 (95% CI 0.36 to 0.46), respectively. All children had reduced SHS exposure at home after the legislation, irrespective of household SES and compositions. Low household income, low parental education level, living with grandparents or living with other adults was individually associated with increased SHS exposure. DISCUSSION: The proportion of children exposed to SHS at home in Taiwan declined substantially from 2005 to 2009 after smoke-free legislation, and fell further by 2013, irrespective of SES and household compositions. Still, inequality in SHS exposure at home by SES and household composition warrants future research.

Health literacy as the missing link in the provision of immigrant health care: A qualitative study of Southeast Asian immigrant women in Taiwan.

OBJECTIVES: Language and communication barrier are main contributors to poor health outcomes and improper use of health care among immigrants. The purpose of this study was to explore and understand specific language and communication problems experiences by Southeast Asian immigrant women in Taiwan. DESIGN: This qualitative study used focus groups and in-depth interviews to uncover the experiences of immigrant women regarding their access to and utilization of health care in Taiwan. PARTICIPANTS: Eight focus groups were conducted with 62 Southeast Asian immigrant women and 23 individual in-depth interviews with a wide range of stakeholders who had diverse background and intimate knowledge of immigrant-relating health care issues were performed. RESULTS: Directed content analysis was applied and identified four major themes concerning conditions that influenced immigrant women's use of health information and services: (1) gaining access to health information, (2) navigating in health care delivery system, (3) interactions during health care encounters, and (4) capability of using health information and services. Findings from this study suggest that, without basic language and literate skills, the majority of immigrant women had inadequate health literacy to manage health information and navigate the Taiwan health care system. Interpersonal communication gap between immigrant women and health care providers exists because of lack of health literacy in addition al language and cultural barriers. CONCLUSION: With limited language and health literacy skills, immigrant women face numerous challenges in navigating the health care system, interacting with health care providers, and gaining access to proper health care. Future efforts are necessary to enhance individual's health literacy and establish health literate environment.

Maternal and Hospital Factors Associated with First-Time Mothers' Breastfeeding Practice: A Prospective Study.

Continuity of breastfeeding is infrequent and indeterminate. Evidence is lacking regarding factors associated with breastfeeding at different postpartum time points. This prospective study investigated the change in, and correlates of, breastfeeding practices after delivery at a hospital and at 1, 3, and 6 months postpartum among first-time mothers. We followed a cohort of 300 primiparous mothers of Taiwan who gave birth at two hospitals during 2010-2011. Logistic and Cox regression analyses were performed to determine factors that were correlated with breastfeeding practices. In the study sample, the rate of exclusive breastfeeding during the hospital stay was 66%; it declined to 37.5% at 1 month and 30.2% at 3 months postpartum. Only 17.1% of women reported continuing breastfeeding at 6 months. Early initiation of breastfeeding, rooming-in practice, and self-efficacy were significantly related to exclusive breastfeeding during the hospital stay. After discharge, health literacy, knowledge, intention, and self-efficacy were positively and significantly associated with breastfeeding exclusivity. Later initiation (hazard ratio=1.53; 95% confidence interval, 1.05, 1.97), shorter intention (hazard ratio=1.42; 95% confidence interval, 1.13, 1.68), and self-efficacy (hazard ratio=0.98; 95% confidence interval, 0.96, 0.99) were important predictors of breastfeeding cessation within 6 months of delivery. Continuous breastfeeding practice for 6 months is challenging and difficult for new mothers. Results showed that factors related to breastfeeding varied over time after delivery. Interventions seeking to sustain breastfeeding should consider new mothers' needs and barriers at different times.

Explaining selected health behaviors in a national sample of Taiwanese adults.

Extant research provides little evidence about how health literacy, self-efficacy and health locus of control are related to each other in affecting health behaviors. The purposes of this study were to examine the associations among health literacy, self-efficacy and health locus of control and how the three factors are related to health behaviors using data from a national survey of Taiwanese adults. The analysis showed moderate correlations among health literacy, self-efficacy and locus of control, suggesting that they were independent, albeit correlated, factors. Moreover, we found in most cases that health literacy, self-efficacy and locus of control had independent associations with health behaviors. Of the three factors, self-efficacy had the most consistent and positive associations with health behaviors. Our findings suggest that efforts to promote and sustain health behaviors need to focus on improving individuals' emotional states and correcting their faulty self-beliefs and habits of thinking. Health education campaigns and enhancement of literacy skills alone may not achieve the desirable goal of behavioral change.

Accuracy in self-reported health literacy screening: a difference between men and women in Taiwan.

OBJECTIVE: Self-reported screening questions are considered as an effective way to identify patients with limited health literacy. Yet research has shown that individuals tend to over-report their reading level. Moreover, the likelihood of over-reporting may differ between gender groups. This study examined if systematic differences exist between men and women in their response to self-reported screening questions. DESIGN: A national survey in Taiwan with participants selected using a multistage stratified, probability-proportional-to-size sampling strategy. PARTICIPANTS: A total of 5682 Taiwanese adults aged 18 and older were sampled and recruited. Of those adults, 3491 participated in the survey, resulting in a 62.1% response rate. Both gender groups were equally represented in the final study sample. MAIN MEASURES: Self-reported health literacy was assessed using two sets of questions that asked how difficult it was for the respondent to understand written health materials and how often the participant needed assistance from others to understand written health materials. The objective level of health literacy was measured using the Mandarin Health Literacy Scale (MHLS). RESULTS: A significant gender difference was observed among participants who had inadequate health literacy: while women's self-report was in line with the MHLS test result, men had a significant tendency to over-report their comprehension of health information. CONCLUSIONS: In Taiwan, screening questions are prone to socially desirable response and may underidentify male patients with inadequate health literacy. Development of a brief and easy-to-use health literacy test may be a more effective approach to health literacy screening in clinical settings. Alternatively, clinicians can verify patient comprehension of health information via the 'teach back' or 'show me' technique in order to improve communication and patient care. Research is needed to examine if gender differences in self-report of health literacy exist in other countries.

Impact of tobacco control policies on adolescent smoking: findings from the Global Youth Tobacco Survey in Taiwan.

AIMS: To assess the impact of a set of comprehensive tobacco control policies implemented in Taiwan in 2009, including extensive smoke-free policy, advertisement ban, pictorial warning and price increase, on adolescent smoking prevalence. DESIGN: Five waves of cross-sectional surveys. SETTING: Taiwan, 2004-11. PARTICIPANTS: Nationally representative sample of junior high schools aged 13-15 years, in a biennial survey, total sample size 101,100. MEASURES: Core questionnaire of the Global Youth Tobacco Survey, including ever smoking, 30-day smoking and number of cigarettes smoked. The magnitude of prevalence change before and after the 2009 policy implementation was quantified by adjusted odds ratios estimated by piecewise logistic regression models. FINDINGS: The 30-day smoking prevalence demonstrated an upward trend [odds ratio (OR) = 1.06, 95% confidence interval (CI) = 1.02-1.10] between 2004 and 2008. Significant decline in 30-day smoking prevalence after the 2009 law implementation was observed (OR = 0.84, 95% CI = 0.71-0.99). Those living in non-city areas demonstrated a greater magnitude of change. In addition to changes in prevalence, we observed some delay in the age starting smoking, reduction in smokers who smoke fewer than one cigarette per day, and decrease in smokers who did not buy cigarettes. The decline in smoking prevalence was contributed primarily by the reduction in experimenters. CONCLUSION: The comprehensive tobacco control programme introduced in Taiwan in 2009 was associated with a reduction in adolescent smoking, particularly among those in earlier stages of smoking and those who resided in non-city areas.

Disposable income with tobacco smoking among young adolescents: a multilevel analysis.

PURPOSE: Prior studies examining the connection between disposable income and adolescent smoking often yielded mixed results, partly due to the lack of consideration for contextual variables. In the present study, we sought to broaden understanding of disposable income on adolescent smoking behaviors via both absolute and relative perspectives in the school context. METHODS: We obtained data from the 2010 Global Youth Tobacco Survey (GYTS) in Taiwan. Information concerning sociodemographics, disposable income, smoking history, and contextual smoking exposure (e.g., school) were assessed via self-report. Recent-onset smokers were defined as those who had their first cigarette within two years of the survey. Complex survey and multilevel analyses were carried out to estimate association. RESULTS: Adolescents with higher monthly disposable income were 2∼5 times more likely to start smoking and become regular smokers. Having the least disposable income in a class appeared linked with increased risk of tobacco initiation by 40% (95% confidence interval [CI]: 2%-91%). Pupils' odds to start smoking were lowered to .70 when the majority of schoolmates had low disposable income (95% CI: .51-.99). CONCLUSIONS: Adolescent risk of smoking initiation may be differentially affected by individual- and contextual-level absolute and relative disposable income. Future research is needed to delineate possible mechanisms underlying unfavorable health behaviors associated with disposable incomes in early adolescence.

Low-temperature poly-Si nanowire junctionless devices with gate-all-around TiN/Al2O3 stack structure using an implant-free technique.

In this work, we present a gate-all-around (GAA) low-temperature poly-Si nanowire (NW) junctionless device with TiN/Al.

A junctionless SONOS nonvolatile memory device constructed with in situ-doped polycrystalline silicon nanowires.

In this paper, a silicon-oxide-nitride-silicon nonvolatile memory constructed on an n+-poly-Si nanowire [NW] structure featuring a junctionless [JL] configuration is presented. The JL structure is fulfilled by employing only one in situ heavily phosphorous-doped poly-Si layer to simultaneously serve as source/drain regions and NW channels, thus greatly simplifying the manufacturing process and alleviating the requirement of precise control of the doping profile. Owing to the higher carrier concentration in the channel, the developed JL NW device exhibits significantly enhanced programming speed and larger memory window than its counterpart with conventional undoped-NW-channel. Moreover, it also displays acceptable erase and data retention properties. Hence, the desirable memory characteristics along with the much simplified fabrication process make the JL NW memory structure a promising candidate for future system-on-panel and three-dimensional ultrahigh density memory applications.

Health literacy and women's health-related behaviors in Taiwan.

Extant health literacy research is unclear about the contribution of health literacy to health behaviors and is limited regarding women's health issues. The primary purpose of this study is to investigate the association between health literacy and five health behaviors (Pap smear screening, annual physical checkup, smoking, checking food expiration dates, and monitoring physical changes) in women and to test whether the association is mediated by health knowledge. A national sample of 1,754 female adults in Taiwan was included in the study. Result showed that health literacy was positively and independently related to checking food expiration dates and monitoring physical changes, and that health literacy was not related to physical checkup and Pap smear screening. Interestingly, women with high health literacy were more likely to be a current smoker. Study findings suggest that efforts to improve health promotion behaviors in women should consider health literacy as an important factor and that the effect of health literacy on health prevention behaviors may vary by women's access to care.

Acculturation in the adaptation of Chinese-American women to breast cancer: a mixed-method approach.

AIMS: To explore how and to what extent acculturation and immigration affect Chinese-American immigrant women's breast cancer experience. BACKGROUND: Acculturation is an important indicator for immigrant health. Less empirical research has been conducted on the association between acculturation and breast cancer experience among Chinese immigrant women in the USA. DESIGN: A mixed methods study. METHODS: A total of 107 Chinese-American women with breast cancer completed the structured questionnaire survey, and 16 women completed face-to-face in-depth interviews. RESULTS: In the quantitative findings, acculturation was related to health beliefs, social support and life stress. Cultural interpretations of the qualitative information are offered to show that breast cancer experience was intertwined with cultural adaptation in a given immigrant environment. Chinese cultural beliefs persistently, even after years of immigration, guide Chinese-American immigrant women to respond to breast cancer across the meaning of health and illness, family ties and involvement and social interaction. CONCLUSION: Our findings show that acculturation is related to health beliefs, social support and life stress in the trajectory of breast cancer adaptation among Chinese-American immigrant women. Life stresses derived from immigration bring additional difficulties for immigrant women living with cancer. RELEVANCE TO CLINICAL PRACTICE: This study pinpoints that traditional cultural beliefs and immigration stress may influence Chinese-American women to cope with breast cancer. To promote culturally sensitive cancer care for immigrants, healthcare professionals should be aware of and learn intercultural competence. Ethnic social support or outreach healthcare programme may benefit new immigrant families or the immigrant families, who lack social connection, to cope with cancer.