Assessment of Colon Cancer Literacy in Screening Colonoscopy Patients: A Validation Study

doi:10.1016/j.jss.2011.04.036

Journal of Surgical Research

Volume 175, Issue 2, 15 June 2012, Pages 221-226

https://doi.org/10.1016/j.jss.2011.04.036 Get rights and content

Background

Few, if any, instruments assess disease-specific health literacy in colon cancer patients. We aimed to validate the Assessment of Colon Cancer Literacy (ACCL) compared with a standard health literacy test, the Newest Vital Sign (NVS).

Materials and Methods

A convenience sample of screening colonoscopy patients was surveyed. General health literacy was assessed with the NVS and colon cancer literacy with the ACCL. Contingency table analysis was performed. Results are frequency (proportion) or mean.

Results

Sixty-one subjects completed our survey, mean age 64 ± 9 y, 33 (54%) were women, 28 (46%) had a college degree, 38 (62%) had prior colonoscopy, and 19 (31%) worked in healthcare. The sensitivity and specificity of NVS to identify limited colon cancer literacy was 45.7% and 86.7%, respectively, while the sensitivity and specificity of ACCL to identify limited general health literacy was 91.3% and 34.2%, respectively.

Conclusions

The ACCL is a valid, sensitive measure of health literacy. Furthermore, given its focus on clinically relevant content, this instrument may facilitate discussion of diagnosis, treatment, and prognosis with colon cancer patients. ACCL is a novel, valid health literacy instrument that may aid gastroenterologists, colorectal surgeons, and medical oncologists in optimizing patient education.

Introduction

Worldwide, colorectal cancer is the third highest cause for cancer-related mortality [1]. Approximately 145,000 patients are diagnosed with colorectal cancer annually in the U.S., making it the third most common cancer 2, 3. Optimal oncologic outcomes and long-term survival is obtained by a multidisciplinary approach, including primary care physicians, radiologists, gastroenterologists, gastrointestinal surgeons, and radiation and medical oncologists. This approach, combined with improvements in chemotherapeutics, have led to significant improvements on colorectal cancer outcomes in recent years 4, 5.

Despite these advances, little is known regarding the impact of patients' understanding of their disease on outcomes. Adequate health literacy enables the patients to be informed and make appropriate treatment decisions [6]. People with limited or low literacy have less knowledge about their own health conditions [7], more hospitalizations [8], higher health care costs [9], and poorer health status [10]. Adequate health literacy can ease the communication barrier between the physician and the patient and thus facilitate informed treatment decisions. Race and ethnicity are also important in this regard. Emphasizing the importance of these factors in the physician–patient communication in health-literacy, Kelly et al. demonstrated that physicians overestimate patient health literacy in 54% of African Americans, 11% of Caucasians, and 36% of other race/ethnicities [11]. Interestingly, Goodwin et al. found that patients with a prior knowledge of breast, prostate or colorectal cancer had a significant survival benefit 12, 13.

Several instruments have been developed to assess general health literacy based on reading and numeracy skills, such as the Rapid Estimate of Adult Literacy in Medicine (REALM) [14], and the Test of Functional Health Literacy in Adults (TOFHLA) [15]. Limitations of the TOFHLA (time-consuming) and REALM (only assesses reading and pronouncing abilities) led to the development of the Newest Vital Sign (NVS) [16]. The NVS is a brief assessment that utilizes a questionnaire based on an ice cream label [16]. Few, if any, specific assessment tools exist specific for a single specialty 17, 18, 19. Literacy assessment tests based on REALM were developed and validated in vascular surgery, genetics, and dentistry to target specific patients visiting those respective subspecialties 17, 18, 19. The need for disease-specific health literacy assessment was previously identified for colon cancer but has yet to be developed and validated [20].

Prior research in our group has demonstrated the effectiveness of such a module about colon cancer using a 10-question survey 21, 22. The aim of the present study is to validate colon cancer-specific health literacy assessment tool: “Assessment of Colon Cancer Literacy (ACCL)”, against a standard measure of health literacy, the NVS.

Section snippets

Subjects

After Institutional Review Board study approval, and after obtaining permission to use the NVS from Pfizer, Inc., a convenience sample of adult, native English-speaking patients scheduled to undergo open-access screening colonoscopy were recruited at the time of colonoscopy check-in in September 2009. Informed consent was obtained from all subjects prior to enrollment, and subjects were anonymously surveyed. Subjects with a prior history of colon cancer, inflammatory bowel disease, and those

Results

A total of 61 subjects completed the ACCL and the NVS surveys; one subject was excluded for not completing the surveys prior to being called for their colonoscopy; one subject with prior history of colon cancer was excluded. In addition, one outlier (a physician) was excluded due to an extreme discrepancy between the score on the NVS and ACCL (scored 0 on the NVS and 9 on ACCL); this subject was visibly anxious and distracted during administration of the NVS.

Demographics and baseline

Discussion

We originally designed the ACCL to assess the impact of a multimedia educational intervention on disease-specific literacy in colon cancer patients. The aim of this study was to assess its validity in the assessment of health literacy using a widely acceptable test, which is a standard. The results of our study suggest that the ACCL is a valid tool for assessing health literacy or colon cancer literacy in screening colonoscopy patients based on its high sensitivity of 91.3% in identifying

Conclusion

In summary, the ACCL was a valid tool for assessing colon cancer literacy in screening colonoscopy patients. Our data suggest that patients who score less than 7 on the ACCL have limited health literacy or colon cancer literacy, and can benefit from additional educational intervention, such as evidence-based multimedia programs or enhanced booklets. Such intervention may especially be important in patients who have recently been diagnosed with colon cancer. In those patients, educational

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Patients with limited health literacy have worse preoperative function and pain control and experience prolonged hospitalizations following shoulder arthroplasty
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Patients with limited health literacy (LHL) may have difficulty understanding and acting on medical information, placing them at risk for potential misuse of health services and adverse outcomes. The purposes of our study were to determine (1) the prevalence of LHL in patients undergoing inpatient shoulder arthroplasty, (2) the association of LHL with the degree of preoperative symptom intensity and magnitude of limitations, (3) and the effects of LHL on perioperative outcomes including postoperative length of stay (LOS), total inpatient costs, and inpatient opioid consumption.
We retrospectively identified 230 patients who underwent elective inpatient reverse or anatomic shoulder arthroplasty between January 2018 and May 2021 from a prospectively maintained single-surgeon registry. The health literacy of each patient was assessed preoperatively using the validated 4-item Brief Health Literacy Screening Tool. Patients with a Brief Health Literacy Screening Tool score ≤ 17 were categorized as having LHL. The outcomes of interest were preoperative patient-reported outcome scores and range of motion, LOS, total postoperative inpatient opioid consumption, and total inpatient costs as calculated using time-driven activity-based costing methodology. Univariate analysis was performed to determine associations between LHL and patient characteristics, as well as the outcomes of interest. Multivariable linear regression modeling was used to determine the association between LHL and LOS while controlling for potentially confounding variables.
Overall, 58 patients (25.2%) were classified as having LHL. Prior to surgery, these patients had significantly higher rates of opioid use (P = .002), more self-reported allergies (P = .007), and worse American Shoulder and Elbow Surgeons scores (P = .001), visual analog scale pain scores (P = .020), forward elevation (P < .001), and external rotation (P = .022) but did not significantly differ in terms of any additional demographic or clinical characteristics (P > .05). Patients with LHL had a significantly longer LOS (1.84 ± 0.92 days vs. 1.57 ± 0.58 days, P = .012) but did not differ in terms of total hospitalization costs (P = .65) or total inpatient opioid consumption (P = .721). On multivariable analysis, LHL was independently predictive of a significantly longer LOS (β, 0.14; 95% confidence interval, 0.02-0.42; P = .035).
LHL is commonplace among patients undergoing elective shoulder arthroplasty and is associated with greater preoperative symptom severity and activity intolerance. Its association with longer hospitalizations suggests that health literacy is an important factor to consider for postoperative disposition planning.
The association of health literacy and postoperative complications after colorectal surgery: A cohort study
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At the provider-level, use of understandable words and revision of patient education materials to feature visuals and text at appropriate reading levels are important.5,18,36 Furthermore, multimedia and e-learning interventions may be novel ways to supplement patient education materials, and have been shown to be effective among patients undergoing colonoscopy.37–39 At the organizational-level, use of SSI prevention kits has been shown to improve patient adherence with bowel preparation and reduce rates of SSI after colectomy.40
Health literacy is a determinant of health. Few studies characterize its association with surgical outcomes.
Retrospective cohort study of patients undergoing elective colorectal surgery 2015–2020. Health literacy assessed using Brief Health Literacy Screening Tool. Outcomes were postoperative complications, LOS, readmissions, mortality.
Of 552 patients, 46 (8.3%) had limited health literacy, 506 (91.7%) non-limited. Median age 57.7 years, 305 (55.1%) patients were female, 148 (26.8%) were Black. Limited patients had higher rates of overall complications (43.5% vs. 24.3%, p = 0.004), especially surgical site infections (21.7% vs. 11.3%, p = 0.04). Limited patients had longer LOS (5 vs 3.5 days, p = 0.006). Readmissions and mortality did not differ. On multivariable analysis, limited health literacy was independently associated with increased risk of complications (OR 2.03, p = 0.046), not LOS (IRR 1.05, p = 0.67).
Limited health literacy is associated with increased likelihood of complications after colorectal surgery. Opportunities exist for health literate surgical care to improve outcomes for limited health literacy patients.
Musculoskeletal Health Literacy is Associated With Outcome and Satisfaction of Total Knee Arthroplasty
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Health literacy is an important determinant of health-related outcomes. Multiple studies have been performed investigating the role of health literacy in various medical subspecialties with specialty-specific surveys to better correlate outcome measures [2,16,17]. There is still little research investigating health literacy in orthopedic surgery, but studies have shown that in an orthopedic trauma population, there is limited comprehension of injuries as well as postoperative instructions.
The purpose of this study was to investigate if there is an association between musculoskeletal health literacy with outcome and satisfaction after total knee arthroplasty (TKA).
A cross-sectional study was performed at our tertiary center to include patients between one and six years postoperatively after primary TKA. Patients were provided a survey including basic demographics, validated musculoskeletal health literacy scale (Literacy in Musculoskeletal Problems), Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), and TKA satisfaction (whether they would choose to undergo the same operation again). Patients were categorized as either low or normal health literacy based on number of questions (cutoff 6 out of 9) answered correctly on the Literacy in Musculoskeletal Problems. Statistical analysis included multivariate regression with significance at P < .05.
Four hundred fifty-three individuals fully completed the survey of eligible participants. Two hundred ninety-six individuals (65.3%) had normal health literacy, and one hundred fifty-seven individuals (34.7%) had low health literacy. Average WOMAC (/96) was 18.0 ± 19.7 in the low and 12.1 ± 15.4 in the normal health literacy groups. Patients with low health literacy had significantly higher WOMAC (worse function) than those with normal health literacy (P = .001). Patients with normal musculoskeletal health literacy were significantly more likely to undergo the same operation again (P = .01, odds ratio 2.163).
This study shows that patients with low musculoskeletal health literacy have worse outcome scores and are less likely to be satisfied with their TKA. By identifying these patients preoperatively, emphasis can be placed on enhancing procedure expectations and understanding to improve outcome measures and overall satisfaction.
Public knowledge of low vision and blindness, and readability of on-topic online information
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Part one gathered demographic data; part two included two dichotomous questions and a 10-statement list; finally, part three was used to assess the readability, on a Likert scale, of two on-topic online texts of different complexity. To design part two of the questionnaire-survey the existing literature on health knowledge assessment was examined,13–16 also considering the professional experience of the researchers regarding the beliefs of lay people about basic visual impairment aspects. To explore the actual knowledge of the participants, this part of the questionnaire assessed “declared knowledge”, for which the term awareness will be used, as well as “real knowledge”, for which knowledge will be used.
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Adequate health literacy is a necessity for optimal function following diagnosis and treatment of physical and mental ailments [35,36]. In addition to suboptimal outcomes, patients with decreased health literacy are more likely to require increased hospitalizations when burdened with an illness [37,38]. Individuals with poor health literacy and minimal education have been demonstrated to have unsatisfactory communication with physicians [37,38].
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Between September 2004 and December 2017, operatively treated patients who presented with a long bone fracture non-union were prospectively followed. These patients presented with a variety of fracture non-unions that underwent surgical intervention. Sociodemographic factors were recorded at presentation. Long-term outcomes were evaluated using the Short Musculoskeletal Function Assessment (SMFA), pain scores, post-operative complications and physical exam at latest follow up. The SMFA is a 46-item questionnaire, assessing patient functional and emotional response to musculoskeletal ailments.
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EducationAssessment of Colon Cancer Literacy in Screening Colonoscopy Patients: A Validation Study

Background

Materials and Methods

Results

Conclusions

Introduction

Section snippets

Subjects

Results

Discussion

Conclusion

J Surg Res

Cancer statistics, 2008

CA Cancer J Clin

Advantages of fast-track recovery after laparoscopic right hemicolectomy for colon cancer

Surg Endosc

Impact of neoadjuvant chemotherapy with FOLFOX/FOLFIRI on disease-free and overall survival of patients with colorectal metastases

J Gastrointest Surg

Office of Disease Prevention and Health Promotion—Healthy People 2010

NAS Newsletter

Relationship of functional health literacy to patients’ knowledge of their chronic disease. A study of patients with hypertension and diabetes

Arch Intern Med

Health literacy and the risk of hospital admission

J Gen Intern Med

Relationship between health care costs and very low literacy skills in a medically needy and indigent Medicaid population

J Am Board Fam Prac

Health status of illiterate adults: Relation between literacy and health status among persons with low literacy skills

J Am Board Fam Pract

Physician overestimation of patient literacy: A potential source of health care disparities

Patient Educ Couns

Education
Assessment of Colon Cancer Literacy in Screening Colonoscopy Patients: A Validation Study