A pinboard by
Danielle Muscat

PhD Candidate , University of Sydney


Introduction/objectives From a health promotion perspective, health literacy is seen as a personal asset which offers consumers greater autonomy and control over healthcare decisions. In this way, health literacy is not a static construct but is fluid and subject to change as individuals build health knowledge, develop health-related skills and practices, display health actions, and make informed decisions. We developed a novel health literacy program which included an integrated shared decision-making (SDM) component for adults with lower literacy. The program was delivered in Australian adult basic education settings with the aim to develop communicative and critical health literacy skills.

Methods Using a purposive sampling strategy, we recruited adults (n=22) who had participated in the health literacy program. Semi-structured interviews were conducted by trained researchers to investigate the subjective student experience of engaging in SDM training for communicative and critical health literacy skill-development. Interviews were analysed using the Framework method; a matrix-based approach to thematic analysis. A hybrid process of inductive and deductive coding was used to interpret raw data.

Results We found that our program served two key functions. Firstly, it stimulated awareness that patients have the right to contribute to healthcare consultations and participate in decision-making: “...now we understand that we have an option where we can talk to the doctor” (HLL14D). Secondly, it facilitated skill development across the domains of functional (e.g. communicating symptoms), communicative (e.g. asking questions to extract information about treatment options) and critical health literacy (e.g. integrating new knowledge with preferences) in a way which would progressively allow for greater autonomy and control in health decision-making.

Discussion/implications Tailored health literacy programs can support skill development across functional, communicative and critical health literacy domains. Future research is needed to investigate if and how skills translate into actual changes in practice to support SDM across healthcare contexts. Novel insights from our health literacy program have refined the Verbal Exchange Health Literacy model to better reflect the overlapping constructs of health literacy and SDM for greater alignment between the two research fields.


Racial disparities in patient activation: Evaluating the mediating role of health literacy with path analyses.

Abstract: The aim of this study was to use path analysis methods to determine if health literacy mediates the relationship between race and patient activation.We performed a secondary analysis of data from a randomized controlled trial in elderly, urban, minority patients using path analysis. Path analysis was used to evaluate the mediation of race on patient activation through different variables. Several models were tested for best fit for their effects on patient activation.Across all models, significant mediation paths were identified from race to lower patient activation through health literacy. This relationship remained significant throughout alternative model testing for covariate combinations. The best-fit model included an indirect effect of sex on patient activation through health literacy indicating that the mediation effect of health literacy on patient activation was most profound for African American males. Health literacy had a bigger influence on patient activation for participants with a greater comorbidity than for those with fewer conditions. No significant direct effect was shown between race and patient activation in any of the models.Racial disparities in patient activation were fully mediated by health literacy skills.Future interventions to improve racial disparities in patient activation need to be targeted at improving health literacy.

Pub.: 27 Jan '16, Pinned: 20 Jun '17

Exploring the role of health literacy in the evaluation of online health information: Insights from a mixed-methods study.

Abstract: To gain new insights into the relationship between health literacy and evaluation of online health information.Using a mixed-methods approach, forty-four semi-structured interviews were conducted followed by a short questionnaire on health literacy and eHealth literacy. Qualitative and quantitative data were merged to explore differences and similarities among respondents with different health literacy levels.Thematic analysis showed that most respondents did not question the quality of online health information and relied on evaluation criteria not recognized by existing web quality guidelines. Individuals with low health literacy, despite presenting higher eHealth literacy scores, appeared to use less established criteria and to rely more heavily on non-established ones compared to those with high health literacy.Disparities in evaluation ability among people with different health literacy might be related to differences in awareness of the issue and to the use of different evaluation criteria. Future research should quantitatively investigate the interplay between health literacy, use of established and non-established criteria, and ability to evaluate online health information.Communication and patient education efforts should aim to raise awareness on online health information quality and to promote use of established evaluation criteria, especially among low health literate citizens.

Pub.: 29 Jan '16, Pinned: 20 Jun '17

Improving low health literacy and patient engagement: A social ecological approach.

Abstract: This article posits four principal objectives related to the overarching goal of broadening the conceptualization of health literacy. We propose a social ecological approach to health literacy and patient engagement by illustrating how this multilevel approach offers an array of strategic options for interventions.A social ecological approach supports a broader understanding of health literacy that aligns with increased patient engagement. The ecological model highlights the importance of context, demonstrates how health literacy and patient engagement are inextricably connected, and gives rise to strategies to enhance them both. We illustrate the five multilevel intervention strategies for addressing low health literacy and promoting patient engagement: accumulation, amplification, facilitation, cascade, and convergence strategies. In addition, we provide a theoretical foundation to facilitate the development of interventions to enhance health literacy and ultimately increase patient engagement.The practice implications of adopting a broader social ecological perspective to address low health literacy shifts the field from thinking about individual educational interventions to how individual interventions may be augmented or supported by interventions at additional levels of influence. The potential benefit of adopting a multilevel intervention approach is that combining interventions could produce synergies that are greater than interventions that only utilize one level of influence.

Pub.: 01 Aug '16, Pinned: 20 Jun '17

Relationship between Teach-back and patient-centered communication in primary care pediatric encounters.

Abstract: We proposed and tested a theoretical framework for how use of Teach-back could influence communication during the pediatric clinical encounter.Audio-taped pediatric primary care encounters with 44 children with asthma were coded using the Roter Interaction Analysis System to measure patient-centered communication and affective engagement of the parent. A newly created Teach-back Loop Score measured the extent to which Teach-back occurred during the clinical encounter; parental health literacy was measured by Newest Vital Sign. Logistic regression was used to test the relationship between Teach-back and features of communication. Focus groups held separately with clinicians and parents elicited perceptions of Teach-back usefulness.Teach-back was used in 39% of encounters. Visits with Teach-back had more patient centered communication (p=0.01). Adjusting for parent health literacy, parent age, and child age, Teach-back increased the odds of both patient centered communication [proportional AOR (95% CI)=4.97 (4.47-5.53)]and negative affect [AOR (95% CI)=5.39 (1.68-17.31)]. Focus group themes common to clinicians and parents included: Teach-back is effective, could cause discomfort, should be used with children, and nurses should use it.Teach-back was associated with more patient-centered communication and increased affective engagement of parents.Standardizing Teach-back use may strengthen patient-centered communication.

Pub.: 04 Mar '17, Pinned: 20 Jun '17

Dutch health websites and their ability to inform people with low health literacy.

Abstract: To evaluate whether Dutch online health information (OHI) generally reflects message elements that support information processing and understanding among people with low health literacy.We content-analyzed one hundred Dutch webpages about Ebola, fibromyalgia, ALS, losing weight, borderline personality disorder, hemorrhoids, ADD, bladder infection, shingles, and chicken pox. The codebook covered the following domains: images and videos, readability level, Suitability Assessment of Materials (SAM), advertising, interactive features, and reliability cues.Thirty-seven webpages contained informative images that visualized the text. Twelve webpages incorporated videos, six of which were animations. Readability varied widely, but 79.2% of the texts exceeded the recommended B1 level. Half of the webpages had inadequate SAM scores; five were classified as superior. Interactive features were infrequently used. Many webpages included only a few elements that help users evaluate the reliability of OHI. Four presented a quality label.Over a wide range of health-related topics, Dutch OHI does not generally contain message elements that improve information processing among people with low health literacy.Communication professionals should make better use of digital message features. Videos, narration, and interactivity are scarcely used but can be valuable for people with low health literacy.

Pub.: 19 Jun '17, Pinned: 20 Jun '17