The Direct Practice Improvement of Health Literacy

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The Direct Practice Improvement of Health Literacy

Introduction

The need for health literacy (HL) is always a present one, but depending on a particular population, it might be especially pressing. Thus, the Latino population in the United States (US) is experiencing a disproportionate level of issues related to healthcare, including negative outcomes, as well as medication errors (Larson et al., 2017). In the presented project, it is intended to review this issue and contribute to resolving it.

HL is achieved through multiple methods, including booklets and video/audio materials. It is not clear which of them is better; either seems to demonstrate positive effects for different populations (Smith et al., 2019). In this project, it is proposed to continue to investigate this gap.

The present prospectus includes all the key information about the project. In particular, there is an attempt to describe the relevant literature, background, purpose and clinical questions, and key methodological aspects from project design and data collection to ethical concerns. The resulting document will be further expanded and revised as required for the benefit of the project.

Background of the Problem

The US Latino community has been growing over the past few years. The most recent history of discrimination against Latino people incorporates former President Trumps rhetoric, but the fact that the Latino population in the US proceeds to demonstrate significant disparities in terms of income, healthcare status, and clinical outcomes implies more deeply rooted issues (Larson et al., 2017). The history of Latino discrimination in the US appears to trace back into the 19th century, and nowadays Latinos experience increased risk factors for many diseases, which implies that there is a significant gap (need) for health communication within the community (Ortiz et al., 2019). The presented project is meant to focus on the improvement of HL among the Latino population of the US, specifically in Florida and among the older population (65 and older). The location is explained by convenience for the project and by the significant number of Latino people in it, and the older age is critical because the health concerns are especially prominent in this population. The clinic that will be the project site serves Latino people, including older people, and it has no special Latino HL education.

Problem Statement

It is not known if or to what degree the implementation of HL improvement audios and videos with booklets would impact healthy literacy when compared to more common educational methods (specifically, booklets) among older Latino population (65 and older). It is established that patient outcomes are improved through better HL (Agency for Healthcare Research and Quality, 2015). The specific methods of HL improvement are still being researched (Denny et al., 2017; Yeung et al., 2017), and the use of them for particular populations may require additional investigation. Some evidence indicates that video and other methods of HL improvement are suitable for Latino populations (Boden-Albala et al., 2019). Other options, for example, written materials, might not be as effective (Dueweke & Bridges, 2017). Therefore, it is critical to investigate in greater detail the different effects of varied HL methods on Latino population with a focus on older Latinos.

Purpose of the Project

The purpose of this quantitative, quasi-experimental project is to determine if or to what degree the implementation of using audio- and video-materials with booklets would impact HL when compared to booklet strategy among 65 year and older Latino population in a primary care setting in Florida over the course of one month. The video/audio materials are methods of HL improvement that rely on audio/video approaches. HL impact will be defined as a decrease in the numbers of revisits and improvement in medication adherence/reduction of medication errors. The purpose of the project is justified by the literature, which identifies audio/video materials as a good method of HL improvement (Dueweke & Bridges, 2017). The fact that HL can improve the desired outcomes is documented (Arsenijevic et al., 2020). The purpose and methods are supported by the literature and aligned with the rest of the project elements.

Clinical Question(s)

Based on the presented purpose, the question of interest will consist of discussing the relationships between the key variables. It will use one of the variables as an intervention, and the other two as an outcome. As a result, the following question is proposed.

Q1: To what degree does the implementation of audio/video HL improvement strategy with booklets (intervention) impacts HL as reflected in revisits and medication adherence/ medication errors (what) when compared to booklet strategy among older (65 and older) Latino (population) patients in a primary care setting (setting) in Florida (state) over four weeks?

Variable 1: audio/video HL improvement strategy augmented by booklets. It is the independent variable, which is identified as the use of audio and video materials in health education. It is nominal as there is no way to quantify the variable (Creswell & Creswell, 2018).
Variable 2: revisits. It is the first dependent variable, which is identified as the number of revisits per individual. It is a ratio variable in that it has a zero (Polit & Beck, 2017).
Variable 3: medication adherence/medication errors. It is the second dependent variable, which is identified as a number of adverse medication events performed by the patient, including failure to adhere to medication regimen and medication errors. It is a ratio variable because it has a zero (Creswell & Creswell, 2018; Polit & Beck, 2017).

Additional variables that are likely to be collected will be age and gender of the participants (demographics). There is no need to collect data about the ethnicity since only Hispanic people will be involved. The additional variables will be used to discuss the sample.

Table 1: Characteristics of Variables

Variable	Variable Type	Level of Measurement
Audio/video HL improvement strategy + booklets	Independent	Nominal
Revisits	Dependent	Ratio
Medication adherence/medication errors	Dependent	Ratio

Advancing Scientific Knowledge

There is some conflicting evidence regarding the efficacy of relevant HL improvement methods (Smith et al., 2019). The investigation of HL among Latino populations is a gap. Therefore, the direct areas of interest to the project will result in advancing scientific knowledge.

Furthermore, the theoretical foundations of the project are important. Kurt Lewins change model is often used in healthcare, and its introduction in the present project will further demonstrate its applicability (Wojciechowski et al., 2016). Similarly, there might be some implications for the health belief model (Jones et al., 2014). Therefore, the theoretical foundations of the project will also be the areas of advancing scientific knowledge.

Significance of the Project

The potential results of the project will be usable from several perspectives. A specific introduction into practice (of the educational methods) will be important for the site. Especially if the results indicate positive outcomes, the direct practice improvement will be meaningful. However, the lack of positive outcomes compared to just booklets implies that the project site will have more opportunities and methods of education, which is also a positive outcome.

Naturally, the specific results of the project will also be important for the current literature. There is no direct answer on which method of HL improvement is the best; it is just clear that the specified methods are effective (Smith et al., 2019). Therefore, additional findings on the topic are important.

Finally, the results of the project will have implications for practice outside of the site. They will make suggestions on what is appropriate for HL improvements for the Latino population. Every practitioner who serves the population can benefit from the project.

Rationale for Methodology

The intended methodology is quantitative for the following reasons. Creswell and Creswell (2018), as well as Polit and Beck (2017), highlight the fact that quantitative approaches are best suited for answering the research question, in particular because the question is focused on a relationship between variables. In other words, since the research question is intended for a quantitative analysis of the relationship, it is natural to use quantitative methods for the project.

Qualitative methods, while useful for relevant questions, are not suitable for this project because they are not capable of providing responses regarding relationships the way quantitative methods are. Qualitative methods are aimed at working with in-depth responses to qualitative questions with non-quantifiable phenomena. That is not the case for the present project.

Nature of the Project Design

As highlighted by Creswell and Creswell (2018), as well as Polit and Beck (2017), the presented project would benefit from a quasi-experimental design for the following reasons. First, it aims to discover relationships between variables. Second, it is a direct practice improvement project, so an intervention is in order. Third, the project cannot guarantee the control of the intervention for feasibility reasons. It is only intended to use one group. Therefore, quasi-experiment is the specified approach. As is required to respond to the question, the sample is older Latin people who are involved in the specified primary care clinic in Florida.

Instrumentation or Sources of Data

The data that will be collected will be focused on medication errors and revisits, both of which can be identified through health records revision. It is important that the implementation of the intervention will not be tightly controlled (hence the quasi-experimental nature).

Sources of Data

Electronic healthcare records are used by the clinic, and they are intended to be used by the project. Depending on the IRB requirements, HIPAA considerations may be required. A clinic employee will be employed to avoid exposing potentially identifying information.

Data Collection Procedures

The following steps will be involved in the process of data collection. After approval, planning, and access to the site, the information about the project will be disseminated. It will involve informative leaflets with contact information. Up to 45 of Latino older people who are the patients of the specific clinic will be recruited. According to statistical analysis, this number is sufficient. The issue of consent will be considered. Demographics will be collected. Pre-intervention data will be collected with the help of electronic records used by the clinic. The intervention will be performed, and in four weeks, the post-intervention data will be collected.

Data Analysis Procedures

Some demographics, as mentioned above, will be collected. The demographics, including gender and age, will be analyzed statistically, specifically, with the help of descriptive statistics (most likely, percentages of different subgroups will be determined). The results will be presented with the help of a table and pie-charts.

As highlighted by Polit and Beck (2017), it is preferable to use parametric tests for healthcare research. While it is possible that a non-parametric one will have to be employed, paired t-test is currently intended for inferential statistics required to determine the differences between the pre- and post-intervention data.

Ethical Considerations

As highlighted by Creswell and Creswell (2018), as well as Polit and Beck (2017), it is important to ensure the safety of the participants, as well as their confidentiality and anonymity. It is planned to use ethical methods, including informed consent and patient identifiers for that purpose. The data will be stored securely and eventually destroyed.

Literature Review

This section presents a review of literature for the project dedicated to HL among the Latino population of a specific clinic in Miami. The section will include a description of the theoretical foundations for the project, as well as the relevant themes. The latter will be subdivided into subthemes and employ multiple important references.

Theoretical Foundations/Conceptual Framework

Two primary models will be of interest to the project: Kurt Lewins change model and the health belief model. The former model is related to the process of changing behavior (Wojciechowski et al., 2016). The latter models primary statements are concerned with the efficiency of health communication messages (Jones et al., 2014). Given the specifics of the project, it can be proposed that both models could be applied to the idea of improving HL in the population with the help of effective methods of delivering health messages. The models do not conflict and can be used to understand the underlying principles of HL change, including the independent variable (HL materials) and the dependent ones (the outcomes of HL change).

Review of the Literature

Theme 1. Health Communication Importance

Health communication has an impact on attitudes and self-efficacy, and it has been shown to affect chronic condition management. Overall, health communication and HL are important for diverse populations. One of them is the Latino population.

Impact on Attitudes

Attitudes can inhibit health-seeking behavior.

Project 1. Tam et al. (2017): HL video changed attitude toward aging services.
Project 2. Boden-Albala et al. (2019): improved attitudes through video education.
Project 3. Dueweke and Bridges (2017): booklets improved Latino population attitudes.

In summary, attitudes are important to change. They can be changed with the help of health communication. However, it is not the only effect of HL.

Subtheme 2: Impact on Self-Efficacy and Knowledge.

Self-efficacy is crucial to address according to the theoretical framework of the project (Jones et al., 2014).

Project 1. Davis et al. (2019): improved self-efficacy after online education videos.
Project 2. Lopez-Olivo et al. (2020): booklets and videos improved patient knowledge.
Project 3. Reid et al. (2018): knowledge and self-sufficiency improved after a video.

Self-efficacy is among the things that HL can change. It is also important to advance. More biological aspects of HL can also be introduced.

Subtheme 3: Reducing readmission rates and medication use improvement.

For the sake of the reduction of chronic conditions, readmission rates and medication errors, which are prevalent among the Latino population (Larson et al., 2017), HL is important.

Project 1. Giuliano et al. (2017): short-term improvement in medication knowledge was found for patients over 65 (based on a video HL method).
Project 2. Meta-analysis by Arsenijevic et al. (2020): video can improve adherence.
Project 3. Mathew and Thukha (2018): patient-centered education in various media results in a reduction of readmission rates.
Project 4. Dattilo et al. (2020): leisure education led to improved health outcomes.

Chronic conditions can be affected by HL improvementIt is true for the Latino population. HL is important to improve, and a method of achieving this needs to be offered.

Theme 2. Impact of Video-Audio and Booklet Health Communication

There are multiple benefits to using audio- and video-communication for health messages. There are also benefits to booklet use, but recent literature implies that there might be limitations to it as well. Either method should be investigated with Latino population.

Subtheme 1: Benefits of booklet use and their limitations.

There are both.

Project 1. Enzinger et al. (2020): multicenter quantitative study (186 patients with cancer, mostly older): an educational video and booklet did not improve patient expectations.
Project 2 Dueweke and Bridges (2017): in first-generation Latino immigrants, written HL materials had limited effect on suicide literacy (with respect to attitudes).
Project 3. Smith et al. (2019) suggest that there is no difference between booklet and video plus booklet interventions when it comes to HL in older people.

There is some conflicting evidence on the matter. Overall, booklets can involve positive outcomes, but they might fail even when paired with other methods. More research is required.

Subtheme 2: Emerging method: audio- and video-materials.

The use of audio and video materials is enabled by the modern technology, and it appears to bring positive outcomes.

Project 1. Nokes and Reyes (2019): video improved healthy behaviors in older adults.
Project 2. Eneanya et al. (2020): video for older people led to more satisfaction.
Project 3. Mitchell et al. (2018): video resulted in improved recommendation adherence.
Project 4. Kassavou et al. (2020): improved medication adherence from audio messaging.

In summary, both audio and video materials are an option in improving HL. Multiple positive effects can be found for either. However, it is also important to study them with respect to specific populations.

Subtheme 3: Latino population and HL is a gap.

With the number of the Latino population growing and experiencing significant health issues (Larson et al., 2017), more research on the topic is required. The below-presented literature only recruited Latino people.

Project 1. Ortiz et al. (2019): video plus printed materials lead to improvement.
Project 2. Dueweke and Bridges (2017): written HL did not improve suicide literacy.
Project 3. Sinha et al. (2018): video led to improved self-efficacy (40 older people).

In summary, it is worthwhile to investigate the application of the HL improvement methods to the Latino population. More research may be required because of conflicting evidence. The presented area is a gap in research.

Conclusion

The project intends to explain the relationship between HL improvement and related outcomes through health behavior, which is reflected in the selection of Kurt Lewins change model and health belief model as theoretical foundations. The literature on the topic demonstrates that HL improvement is well-researched, but their application to the Latino population is a gap, especially given the relevance of the Latino population for healthcare services. The literature review justifies the project and provides recommendations on its design.

References

Agency for Healthcare Research and Quality. (2015). Teach back. Web.

Arsenijevic, J., Tummers, L., & Bosma, N. (2020). Adherence to electronic health tools among vulnerable groups: Systematic literature review and meta-analysis. Journal of Medical Internet Research, 22(2).

Boden-Albala, B., Goldmann, E., Parikh, N. S., Carman, H., Roberts, E. T., Lord, A. S., & Quarles, L. (2019). Efficacy of a discharge educational strategy vs standard discharge care on reduction of vascular risk in patients with stroke and transient ischemic attack: The DESERVE randomized clinical trial. JAMA Neurology, 76(1), 20-27.

Creswell, J.W. & Creswell, J.D. (2018). Research design: Qualitative, quantitative, and mixed methods approaches (5^th ed.) Thousand Oaks: CA. Sage Publications.

Dattilo, J., Lorek, A., Sliwinski, M., Chen, S.-T., & Hill, N. (2020). An examination of vide assisted leisure education in middle-aged and older adults. Journal of Leisure Research.

Davis, S. A., Carpenter, D. M., Blalock, S. J., Budenz, D. L., Lee, C., Muir, K. W., & Sleath, B. (2019). A randomized controlled trial of an online educational video intervention to improve glaucoma eye drop technique. Patient Education and Counseling, 102(5), 937-943.

Denny, M. C., Vahidy, F., Vu, K. Y. T., Sharrief, A. Z., & Savitz, S. I. (2017). Video-based educational intervention associated with improved stroke literacy, self-efficacy, and patient satisfaction. PLoS One, 12(3).

Dueweke, A. R., & Bridges, A. J. (2017). The effects of brief, passive psychoeducation on suicide literacy, stigma, and attitudes toward help-seeking among Latino immigrants living in the United States. Stigma and Health, 2(1), 28-42.

Eneanya, N. D., Percy, S. G., Stallings, T. L., Wang, W., Steele, D. J. R., Germain, M. J., & Volanges, A. E. (2020). Use of a supportive kidney care video decision aid in older patients: A randomized controlled trial. American Journal of Nephrology, 51(9), 736-744.

Enzinger, A. C., Uno, H., McCleary, N., Frank, E., Sanoff, H., Loon, K. V., & Schrag, D. (2020). Effectiveness of a multimedia educational intervention to improve understanding of the risks and benefits of palliative chemotherapy in patients with advanced cancer: A randomized clinical trial. JAMA Oncology, 6(8), 1265-1270.

Giuliano, C., Nofar, T., & Edwin, S. B. (2017). Can a short video improve apixaban knowledge in an inpatient setting? Pharmacy & Therapeutics, 42(4), 256-260.

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Kassavou, A., Mirzaei, V., Brimicombe, J., Edwards, S., Maasou, E., Prevost, A. T., & Sutton, S. (2020). A highly tailored text and voice messaging intervention to improve medication adherence in patients with either or both hypertension and type 2 diabetes in a UK primary care setting: Feasibility randomized controlled trial of clinical effectiveness. Journal of Medical Internet Research, 22(5).

Larson, K., Mathews, H., Torres, E., & Lea, C. (2017). Responding to Health and Social Needs of Aging Latinos in New-Growth Communities: A Qualitative Study. BMC Health Services Research, 17(1).

Lopez-Olivo, M. A., des Bordes, J. K. A., Lin, H., Rizvi, T., Volk, R. J., & Suarez-Almazor, M. E. (2020). Comparison of multimedia and printed patient education tools for patients with osteoporosis: A 6-month randomized controlled trial. Osteoporosis International, 31, 857-866.

Mathew, S., & Thukha, H. (2018). Pilot testing of the effectiveness of nurse-guided, patient-centered heart failure education for older adults. Geriatric Nursing, 39(4), 376-381.

Mitchell, S. L., Shaffer, M. L., Cohen, S., Hanson, L. C. Habtemariam, D., & Volandes, A. E. (2018). An advance care planning video decision support tool for nursing home residents with advanced dementia: A cluster randomized clinical trial. JAMA Internal Medicine, 178(1), 961-969.

Nokes, K. M., & Reyes, D. M. (2019). Do brief educational sessions increase electronic health literacy of low-income persons living with HIV/AIDS? CIN: Computers, Informatics, Nursing, 37(6), 315-320.

Ortiz, A. P., Machin, M., Soto-Salgado, M., Centeno-Girona, H., Rivera-Collazo, D., González, D., & Colón-López, V. (2019). Effect of an educational video to increase calls and screening into an anal cancer clinical trial among HIV+ Hispanics in PR: Results from a randomized controlled behavioral trial. AIDS and Behavior, 23, 1135-1146.

Reid, K. R. Y., Reid, K., Esquivel, J. H., Thomas, S. C., Rovnyak, V., Hinton, I., & Campbell, C. (2018). Video education improves heart knowledge and self-care. Journal of Cardiac Failure, 24(8), S97-S98.

Roman, C. J., Guan, X., Barnholtz-Sloan, J. S., Xu, J., & Bordeaux, J. S. (2016). A trial online educational melanoma program aimed at the Hispanic population improves knowledge and behaviors. Dermatologic Surgery, 42(5), 672-676.

Sinha, S., Dillon, J., Dargar, S. K., Archambault, A., Martin, P. Frankel, B. A., & Safford, M. (2018). What to expect that youre not expecting: A pilot video education intervention to improve patient self-efficacy surrounding discharge medication barriers. Health Informatics Journal, 25(4), 1595-1605.

Smith, C. A., Chang, E., Gallego, G., Khan, A., Armour, M., & Balneaves, L. G. (2019). An education intervention to improve decision making and health literacy among older Australians: A randomized controlled trial. BMC Geriatrics, 19(129).

Tam, J. W., Son, C. V., Dyck, D., & Schmitter-Edgecombe, M. (2017). An educational video program to increase aging services technology awareness among older adults. Patients Education and Counseling, 100(8), 1564-1571.

Wojciechowski, E., Pearsall, T., Murphy, P., & French, E. (2016). A case review: Integrating Lewins Theory with Leans System Approach for Change. Online Journal of Issues in Nursing, 21(2).

Yeung, D. L., Alvarez, K. S., Quinones, M. E., Clark, C. A., Oliver, G. H., Alvarez, C. A., & Jaiyeola, A. O. (2017). Low-health literacy flashcards & mobile video reinforcement to improve medication adherence in patients on oral diabetes, heath failure, and hypertension. Journal of the American Pharmacists Association, 57(1), 30-37.

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