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Correlation between Health Literacy and Stroke Education Outcomes
Inadequate health literacy is a pervasive problem with major implications for reduced health status and health disparities. Education is a fundamental strategy of stroke prevention and treatment, but the effect of health literacy on stroke education outcomes has not been reported. In a new study, researchers examined the relationship of health literacy to stroke education outcomes, following stroke education among patients with acute ischemic stroke admitted to an inpatient stroke unit. Completion of stroke education on acute ischemic stroke inpatients before hospital discharge is 1 of 8 core performance measures that the Joint Commission-certified primary stroke centers must conduct [Prev Chronic Dis. 2014;11:E55].
Stroke is the fourth leading cause of death in the United States and the leading cause of physical disability in American adults. Approximately 795,000 cases of stroke are reported in the United States each year; of these cases, 185,000 are recurrent strokes.
The hospital-based, prospective, cross-sectional study was conducted at the University of Florida—Jacksonville, a certified primary stroke center. From August 2009 to June 2010, patients ≥18 years of age admitted to the inpatient stroke unit with acute ischemic stroke who were able to provide informed consent were included in the study.
One-hundred patients were identified and recruited by either the treating neurologist or a stroke unit nurse manager. A neurologist confirmed the diagnosis of acute ischemic stroke, and a computerized tomography scan or magnetic resonance imaging scan confirmed the location and side of the brain infarction. The magnitude of neurological deficit at the time of hospital admission for each patient was delineated by the National Institutes of Health Stroke Scale. Each participant was administered a Mini-Mental Status Exam to test cognitive impairment after obtaining consent. The average patient was 60 years of age, 57% were male, 56% were African American, and 75% earned <$25,000 per year.
Health literacy levels were measured using the short form of Test of Functional Health Literacy in Adults, which contains 36 reading comprehension items. All participants received Joint Commission mandated stroke education administered by a nurse during their hospitalization. The patient education included verbal instructions with the use of illustrative handouts. After the educational session and before discharge, patients’ comprehension and retention of information was evaluated by asking the 5 questions of the Stroke Patient Education Retention (SPER) score, which was assessed using univariate and multivariate analyses (Please see Table below). The SPER score ranges from 0 to 10.
The findings showed that low health literacy was prevalent in this patient population, with 59% having marginal to inadequate health literacy at the time of discharge. Stroke patients who had marginal health literacy (mean score, 7.45) or adequate health literacy (mean score, 7.31) had statistically higher education SPER outcome scores than those identified as having inadequate health literacy (mean score, 5.58). Retention of stroke knowledge was lacking, even with standard stroke post-education; only 12% of patients could identify all 5 warning signs for a stroke, 43% knew their personal risk factors, 85% knew what to do if they developed symptoms of a stroke, 76% knew their medication prescribed for stroke prevention, and 53% knew their type of stroke.
The researchers acknowledged study limitations. There was a lack of evidence or predictive validity concerning stroke patient outcomes. Also, due to the small study cohort, the modeling approach was not significantly powered to detect the effect of many demographic factors on stroke incidence.
“Results of our study reinforce those of other studies that indicate that literacy is a factor contributing to health disparities, both in terms of prevalence of low literacy and the impact of low literacy on education outcomes,” concluded the researchers. “Studies are needed to better understand the relationship of health literacy to key educational outcomes for primary or secondary prevention of stroke and to refine stroke education for literacy levels of high-risk populations.”
